PRINCIPLES OF MEDICINE. 



AN ELEMENTARY VIEW 

OF THE 

CAUSES, NATURE, TREATMENT, DIAGNOSIS AND PROGNOSIS OF DISEASE. 



PRINCIPLES OF MEDICINE. 



AN ELEMENTARY VIEW 



CAUSES, NATURE, TREATMENT, DIAGNOSIS AND PROGNOSIS 



DISEASE. 



WITH BRIEF REMARKS ON HYGIENICS, OR THE 
PRESERVATION OF HEALTH. 



y v by 

CHARLES J. B. WILLIAMS, M.D.. F.R.S. 

A NEW AMERICAN 

FROM THE THIRD AND REVISED LONDON EDITION, 




PHILADELPHIA: 
BLANCH A RD & LEA. 
1857. 



LC Control Number 




tmp96 029109 



PREFACE. 



In this work the attempt is made to place the practice of Medicine on a 
footing somewhat corresponding with that of Physiology, Chemistry, and 
other sciences which equally depend on the accurate observation and rational 
arrangement of facts. If our knowledge of the healthy body, and of its parts 
and functions,, he exact, it ought to be our best guide in the study of the same 
parts and functions in a state of disease. Yet the habit has long prevailed, 
and even still has its avowed advocates, of regarding the phenomena of disease 
as a new and separate order of things, the character and laws of which are to 
be investigated by themselves, and without reference to the standard of health 
from which they deviate; as if diseases were independent entities, and as if the 
body under their influence ceased to possess the same structures and functions 
which it has in health. Happily, however, such irrational dogmas do not 
now find much favour with the members of our profession, who, in proportion 
as they become more enlightened by sound physiology, recognise in it, when 
combined with careful clinical and pathological observation, the best guide to 
the understanding and treatment of disease. 

It must be admitted that there remain considerable doubt and obscurity in 
many subjects, both in Physiology and in Medicine, and the science of one 
and the art of the other must, therefore, still be acknowledged to be imperfect; 
but no one can dispassionately look back on the progress which has been made 
in both departments within the last thirty years, without being encouraged to 
hope for increasing precision in the science and greater success in the art. 

For an additional proof of the existence of a growing interest and confidence 
in rational medicine, I may perhaps be excused in referring to the success of 
the former editions of this work. When first I communicated to my publisher 
my intention of bringing out a work on the Principles of Medicine, I was by 
no means encouraged by the intimation that books on that subject did not 



vi 



preface; 



sell; but no sooner was it discovered that the " Principles" were essentially 
and intelligibly practical, than the demand for the work became sufficient to 
exhaust two editions, long before I could find time to replace them. Several 
editions have also appeared on the Continent and in America. 

I have now to express my regret that the incessant engagements of my 
practice have so long delayed the appearance of this edition. In fact, it might 
have been deferred much longer, if I had not secured the valuable assistance 
of my friend and former pupil, Dr. R. J. Mann, who has contributed several 
articles on recent investigations in Physiology and Animal Chemistry, and 
has taken great pains in revising the composition of the whole work. To my 
friend, Mr. George Gulliver, I am also indebted for looking over the chapters 
on Diseases of the Blood and Inflammation, and for very important micro- 
scopic contributions on these subjects. Free reference has been made to va- 
rious recent authors on Physiology and Pathology; but I would especially 
mention the works of Dr. Carpenter, Mr. Paget and Professor Rokitansky, as 
sources from which I have derived much valuable information. 

It is right to mention that several of the early sheets of this work have been 
printed more than twelve months, which will account for the absence from 
them of reference to the most recent facts. 

49 Upper Brook Street, 
August 8th, 1856. 



* 



CONTENTS. 



Preface Page iii 

PRINCIPLES OF MEDICINE. 

Paragraph. 

Explanation of the Object of the Work p. 33 

1, 2 Principles of Medicine. Synonyms. Whence deduced. Division into etiology, 
3, 4 pathogeny, general therapeutics, and other subjects . . . . p. 33 

Definition of Disease p. 33 

5 Standards of comparison. Definition of health. Deviations from health; in func- 

tion; in structure. 

6 Physiology a standard of healthy function; anatomy — of structure. 

7 Definitions of disease. 

8 Variations in the standard of health. Examples. 

CHAPTER I.— ETIOLOGY— ON THE CAUSES OF DISEASE. 
Section I. — Nature and Division of Causes . . . .p. 34 — 40 

9 Definition of causes of disease. Antecedent circumstances apt to he mistaken for 

causes. This error to be avoided by proving their occasional absence, and 
investigating the intimate nature of disease. Example. 

10 Causes of disease intrinsic and extrinsic. Examples. 

11 Causes of disease not sure in operation; except those which are very strong. 

12 They generally require predisposition. Examples. 

13 Causes divided into remote and proximate. Remote divided into predisposing 

and exciting. 

14 Co-operation of predisposing and exciting causes generally necessary. Examples. 

15 Exceptions. 

16 Predisposition, generally deficiency of natural power of resistance. Examples of 

17 the operation of this resisting power. 

18 Predisposition from error of function or structure. Other terms for predisposing 

19 causes; why sometimes inapplicable. Division and nomenclature of causes 
conventional. Obscurity of causation. 

Section II. — Predisposing Causes of Disease . . - .p. 40-— 52 

20 Classification of predisposing causes. 

21, 22 I. Debilitating causes and their modes of operation. Imperfect nourishment. 

23 Impure air. Excessive exertion of body or mind. Want of exercise, and 

24 sedentary habits generally. Long continued heat. Long continued cold. 



ViU 



CONTEXTS. 



Paragraph. 

25 — 28 Habitual intemperance. Depressing passions. Excessive evacuations. 

29, 30 Previous debilitating diseases. 

31, 32 II. Excitement, examples. III. Previous disease; operating by change of struc- 

33 ture; by persistence of cause. Examples. 

34, 3-5 IV. Present disease or defective function. Zymotic material in the body. 

36, 37 V. Hereditary constitution. VI. Temperaments. Definition and nature; san- 

38 — 41 guine; phlegmatic; bilious; nervous. Diathesis. VII. Age, and its predis- 

42 — 46 positions. Infancy, Childhood. Puberty. Full-growth. Adult age. Old 

47 — 49 age; influences exemplified in vascular and nutritive functions. VIII. Sex. 

GO IX. Occupation. 



Section III. — Exciting Causes op Disease . . . . . p. 52 — 95 

51 Operation of exciting causes. Division into cognizable and non-cognizable. 

Classification. 

52 I. Cognizable Agents. (1.) Mechanical causes: examples of their physical 

effects. Vital operation of severe injuries. 

53 (2.) Chemical causes: extrinsic; intrinsic; modes of operation, as local irritants, 

as corrosives, as septics, and as chemical alteratives; examples of their 
effects. 

54,55 (3.) Ingesia. Non- alimentary : condiments; action of salt in excess. Intoxi- 

56 eating liquors, use and abuse of. Delirium tremens ; principles of treatment. 

57 Tea and coffee. Water. Adulterations of food, impure water, medicines, 

58 Aliment, unfit in quality ; a clue mixture requisite. Simple principles, such 
as fibrin, starch, gum, &c. insufficient. Bread the staff of life. Dr. Prout's 

59 views on aliments, sanctioned by familiar experience. Extent of conversion 
of the elements of food by digestion. Dumas' views; objections. Experi- 

60, 61 nients of Petroz and Boussingault. Liebig's views. Effects of alimentary 
principles; albuminous, gelatinous, oleaginous, farinaceous, and saccharine. 

62, 63 in defect, in excess, or bad in quality. Adaptation of food to climate, &c. 

Action of oil, starch, sugar, vegetable acids, &c. Aliment generally, in ex- 
cess. Defective. Symptoms of inanition. Chossat's experiments on star- 
vation. Liability of the ill-fed to zymotic diseases. 

64 (4.) Violent exertion, effect on the heart, brain, lungs, and other organs. Par- 

65 tial exertion. Exhaustion from fatigue. Want of exercise. 

66 (5.) Mental emotion. Strong. Slow emotion. Mental anxiety. Excessive 

mental exertion. Wear and tear. 

67 (6.) Excessive evacuation. Effects. Syncope, cerebral, and cardiac. Other 

effects and resulting diseases. 

68 (7.) Retention, Diminution, and Suppression of Evacuations, alvine, urine, bile, &c. 

69 Lower degrees common in disease. Suppression of artificial discharges ; of 
cutaneous eruptions, &c. 

70 (8.) Defective cleanliness, ventilation, and drainage. Their prevalence; modes 

71 in which they excite disease. Filth, action on skin, &c. Filth in dwellings. 

72 Defective ventilation often insidious in its operation. Evil results, in dwell- 

73 ings and public buildings. Defective drainage; results of effluvia from cess- 
pools. London sewers. Entrapped drains. Causes and consequences'. 

74, 75 (9.) Temperature and changes. Effects of extreme heat or cold. Cold, applied 
generally and locally. Dr. James Arnott's method of applying cold. Power 
of the body to resist cold. Burns and scalds. Shock to the system. Ex- 

76 periments of Sir A. Cooper and Chossat on cold. Stimulating effects of heat. 

77 Partial application of heat. Coup de soleil. Sedative effects of cold. In- 



CONTENTS. 



IX 



Paragraph. 



tropulsion of blood. Effect on the arteries. Indirect effects of cold. Chil- 

78 Mains and frostbite. Warmth to be restored in benumbed parts, gradually. 

79 Mode in which cold excites internal disease. Dr. Alison's views: objections. 
It acts by deranging the circulation, and chemical changes of the blood. 

80 Symptoms of "cold caught." Railway draughts. Fogs. Ozone. Means 
of diminishing susceptibility to cold. Cold bathing. Water cure. Good 

81 and bad effects. Effects of cold proportioned to previous state of the body. 
Atmospheric changes. 

II. Non-cognizable Agents. — Zymotic poisons divided into Endemic, Epi- 
demic, and Infectious. 

82 (I.) Endemic Poisons. Proofs of their existence. Sources. Malaria. Na- 
83, 84 ture of malaria. Its properties. Localities of malaria. Its virulence in 

85 proportion to heat with moisture. Diseases caused by malaria. Periodi- 

86 city of their attacks, causes of this. Kinds of malaria. Endemic diseases 
from cognizable causes. 

87, 88 (II.) Epidemic Poisons. Proofs of their existence. Epidemic. Cognizable 
89, 90 causes distinguished from non-cognizable. Epidemic constitutions or pe- 

91 riods. Nature of epidemic influences. Dr. Prout's observations. Ani- 

92 malcule origin of epidemic diseases ; Linnseus ; Sir H. Holland, &c. Ehren- 
berg's observations. 

93, 94 (HI.) Infectious Poisons. Proofs of their existence. Modes of infection: by 
95, 96 wounds; by contact; by aerial communication; by several modes. Difii- 

97, 98 culties of explaining infection. Analogy of fermentation; of animal and 

99, 100 vegetable generation ; examples. Parasitic view of infection confirmed by 

101 circumstances which promote and check it. Character of cholera infec- 

102 tion. Peculiarities of infectious diseases, of endemic diseases, of epidemic 

103 diseases. Diseases propagated in several ways. Pestilences. General 

104 operation of all these causes depressing, but may excite reaction. Effect 

105 modified by the weather. Means of checking or counteracting zymotic 
poisons. Antiseptics. Stimulants. Tonics. Eliminants. 



CHAPTER II.— PATHOLOGY (PROPER)— THE NATURE AND CONSTITUTION 

OF DISEASE. 

106 Disease composed of elements. Knowledge of these essential to medical 

science. Analogy with chemistry, &c. Primary elements of structure and 

107 function; healthy and diseased. Primary elements of disease. Alterations 

108 of these elements in degree, and in kind. Table of primary elements of 

109 disease. Table of proximate elements of disease; in excess, defect, and 

110 perversion. These elements are the especial objects of general patho- 
logy . . . . . . .p. 95—97 

FUNCTIONAL DISEASES— PRIMARY ELEMENTS. 
Section I. — Diseased Irritability . . p. 97 — 102 

111 Irritability. The distinctive property of muscular fibre. Dependent on sup- 

ply of blood. Structure of muscular fibre. 
112 — 114 In excess. Varieties in strength, in mobility, and in duration. Examples. 
115 Causes. Remedial measures. 

116 — 118 Defective, in force, mobility. Examples. Connexion of irritability with 
119 nerves not essential. Remedial measures. 



X 

Paragraph. 
120 

121, 122 
123, 124 



125 



120 



127, 128 

129, 130 

131 

132 

133—136 
137, 138 



139 

140,141 
142 

143, 144 
145 

146 
147 



148, 149 
150, 151 
152 

153 



154 
155 

156, 157 



CONTEXTS. 



Section II.— Diseased Tonicity . , . p. 102—105 

Tonicity; description; function ; distinct from irritability ; as proved by dif- 
ferent effects of heat and cold. Long recognised practically. 
Excessive. Examples; effect on pulse. Remedial measures. Sedatives. 
Cold: 

Defective. Examples : atony, retarded and dichrotous pulse. Remedial mea- 
sures. Tonics. 

Elementary Nervous Functions. Dependent on supply of blood. In- 
fluenced by poisons ; mechanical irritation; heat, &c. Expenditure of ner- 
vous matter . . . . . p. 106 — 107 

Section III. — Diseased Sensibility . . .p. 107 — 115 

Sensibility referable to the nervous system, and divided into the centric and 
local. 

General. Excessive, from excitement, from disease, from temperament. Pa- 
thological causes. Remedial measures. Narcotics. Tonics. Anassthesis 
by inhalation of chloroform and ether. Mode of action. Cautions. 

Defective. Causes: from disease, age, temperament. Remedies. 

Perverted. Examples; causes. Remedies. 

Local sensibility. Variations illustrated by experiment. Pathological causes. 
Excessive, in orifices, in internal organs. Pain and other varieties. Re- 
medial measures. Local anodynes. Benumbing cold. Defective. Para- 
lysis of sensation. Remedies. 

Section IV. — Diseased Voluntary Motion . . p. 115 — 120 

Division into general and partial. 

General voluntary motion, in Excess : examples. Phrensy; Hysteria; taran- 
tulism, &c. Defective: examples. Lethargy; catalepsy; hysteria, &c. 
Perverted: examples. Chorea; delirium tremens; shaking palsy, &c. 

Partial, excessive. Tricks; fidgets. Defective; pathological causes: exam- 
ples. Remedies for diseased voluntary motion. Excessive. Narcotics; 
calmants ; douche. Modes of action of these remedies. Remedies for de- 
fective volition. Stimulants. Mental excitement. Revulsives. Reme- 
dies for perverted volition. Narcotics; tonics. Eemedies for locally dis- 
eased volition. Electricity, &c. 

Section V. — Diseases of Reflex and Sympathetic Nervous 

Influence . . . . . .p. 121 — 130 

Natural reSex function : examples. Excessive, in involuntary muscles : ex- 
amples. In voluntary muscles : examples. Convulsions ; centric and eccen- 
tric. Partial, by reflected irritation; spasms; cramp, &c. Irritation of 
involuntary muscles ; the spinal marrow the centre of reflexion. 

Pathological causes of inordinate excito-motion ; irritation of spinal marrow 
or its nerves; accumulation by rest; from action of opium, &c. Epileptic 
fits. Action of strychnia and other poisons. Tetanus. Hydrophobia. 

Defective reflex motion. In coma, asphyxia, sinking, &c. Sleeplessness from 
exhaustion. 

Remedial measures for excessive reflex action. Narcotics, nervous sedatives, 
stimulants, chloroform, tonics. For defective. Stimulants; opium. 

Reflected or sympathetic sensations. Examples. Spinal and superficial sensi- 
bility ; involuntary reflex action; chorea. Remedies. 



CONTENTS. 



XI 



Section VI. — Diseased Secretion . . .p. 130 — 140 

Paragraph. 

158 Secretion clue to a vital property; aided by chemical affinity; not to be 

ascribed to nervous influence. 
159 — 161 Changes due to altered supply of blood, or to nervous influence. Excessive. 
162 — 164 Effects : forwards; examples: backwards; on the organ ; examples. On the 
165, 166 blood: examples. Relations of bile and urea. Remedies. Depletion and 

other evacuations. Astringents. Alteratives. 
167 — 169 Defective secretion. Causes. Effects: forwards; examples: backwards; on 
170, 171 the organ; examples. Suppression of excretions; urasmia, choloemia, &c. ; 
172, 173 extreme; moderate; in idiopathic and symptomatic fevers, gout, rheuma- 
174, 175 tism, and other diseases. Remedies, through the circulation. Special 
176 — 178 stimulants. Alteratives. Tonics. Substitutes for defective secretion. 

Perverted secretion. Examples. Effects. Remedies. 

Section VII. — Diseases of the Constituents of the Blood p. 140 
179 Constituents of the blood, when altered, form elements of disease. 

180, 181 Enumeration of constituents and modes of alteration. Chemical composition 
of the blood. 

Disease of Red Particles .... p. 140 — 148 

182 — 184 Natural offices, composition, and proportions. Excessive. Examples. Signs 
and effects. 

185,186 Deficient. Examples and effects. Alterations; in colour; in shape and size ; 

187,188 breaking up. Arterial change ; cause. Mulder's and Carpenter's notions. 

189, 190 Mr. W. Jones' observations; explanation. Mr. Gulliver's observations. 

191 — 193 Origin of red particles. Causes of their decrease. Spoilt blood. Disor- 
ders of spleen and uterus. Remedies for excess, defect, and alteration of 
red particles. 

Section VIII. — Fibrin and White Corpuscles . . p. 148 — 161 

194 Nature of fibrin. Structure in washed clot, or lymph ; circumstances inducing 

195 fibrillation; composition; an oxy-protein. Purposes: materials of tex- 
tures. White corpuscles. Excess of fibrin. Examples in inflammation. 
Signs and effects. Increase of white globules, at expense of red. Defi- 

196, 197 ciency of fibrin. Examples; fluidity of blood, in fevers; in Gaspard's ex- 
198 periments, &c. Causes. Effects : hemorrhage ; congestion, venous mur- 

murs, &c. Magendie's experiments. 
199 — 201 Alterations in quality : apparent from character of coagulum, which shows 

202 properties of self-coagulation, contraction, and separation. Self-coagula- 

203 tion ; varieties and causes ; its occurrence within the vessels. Contraction ; 
294,205 varieties and causes; cupped blood. Separation; causes, varieties. Causes 
206, 207 of the buffy coat. Appearances of coagulated blood. Large clot; small 

208 clot. Separated and cupped ; mode of exhibiting these properties. Source 

209 of fibrin, and formation of white globules. Increase by inflammation. Ma- 
• terial of coagulable lymph. Varieties. Coagulation of fibrin during life. 

Vegetation and polypi. 
210,211 Remedies for Excess of Fibrin. Blood-letting. Evacuants. Narcotics. Cod 

oil. Mr. Blake's experiments. 
212 Remedies for defect ; diet ; regimen ; stimulants ; tonics ; antiseptics ; oxydating 

agents. 

213 — 215 Means of altering quality of fibrin; depletion; alteratives; salines. Tonics; 
diet and regimen. 



xii 



CONTENTS. 



Paragraph. - 

Section IX. — Albumen and other Animal Principles Dissolved in the 
Serum .... . p. 161—163 

216 Natural proportion and offices of albumen. 

217, 218 Excess. Examples. Causes. Remedies. 

219,220 Defect. Examples. Effects. Dropsical diathesis. Remedies ; by checking 
waste ; by increasing supply. 

Section X. — Fatty and other Combustive Matters . p. 163 — 166 

Kinds of fat in the blood. Sources. Sugar in the blood. 
Excess. Examples. Milky serum. Depends on the presence of unassimi- 
lated chyle. Fat formed by degeneration of albumen; fatty cachgemia; re- 
medies. Obesity. Defect. Examples. Causes of atrophy ; remedies. 

Section XI.— Saline and Mineral Matters . . p. 166—168 

225 Thirst caused by salt. Natural, proportions; uses. Excess — scurvy? 

227 Defect: in yellow fever and malignant cholera. Effect of saline injections. 

Use of salines in fevers. Treatment of cholera. 

Section XII.— Water . . . . .p. 168—170 

228 Natural proportion. 

230 Excess. Examples and effects. From too much drink. Deficiency. Ex- 

231 amples. Symptoms. Causes. Effects of cholera — of abstinence from li- 
quids. Remedies for excess and defect. Water cure and dry diet. Drink- 
ing: use and abuse. Water increases waste of tissues. 

Section XIII. — Changes in the Blood by Respiration . p. 170 — 175 
232—234 Analysis of changes. Excess. Examples in disease? Inhalation of oxygen ; 



effects. 

235, 236 Defect: the element of asphyxia. Effect proportioned to suddenness as well 

237 as degree. Explanation of this. Analysis of asphyxia. Classification of 

238 symptoms. Defect gradually induced. Hybernation. Cyanosis : state of 

239 the functions; little muscles and much fat; with defective respiration. 

240 Emphysema. Remedies for defect; Lowering functional activity. Treat- 
241,242 ment of asphyxia. Stimulants. Warm bath. Promoting respiration. 

243 Other means of arterializing the blood. Treatment of congestion of apnoea. 

244 Diet in dyspnoea. 

Section XIV. — Changes in the Blood by Secretion . 175 — 182 

245 . Defective secretion of urine. Experiments of Prevost and Dumas. Effects 

246 of diseased kidneys. Views of Frerichs. Acute and chronic albuminuria. 
249 Defective secretion of bile. Examples. Effects on blood, &c. Bilious 

251 attacks. Perspiratory nature of secretion; checked by cold; effects. Vi- 
carious action of skin and kidneys. Rheumatism ; increased acid in blood ; 
materies morbi. Remedies to be directed to this element. 

252 Treatment of rheumatism: by nitre; lemon juice; the author's plan. Water 

cure. 

Section XV. — Changes in the Blood from the Transformation of 
Chyle and of the Textures of the Body . . 182 — 188 

253 Natural changes imperfectly known. Gout and other lithic acid diseases. 

254 Decay of textures. Causes: rich and too highly azotized food. Treat- 
ment of uraemia. Treatment of cholasmia; of bilious attack. Morbid 
effects of lithic acid on the kidneys. Nephralgia and nephritis. Gout in 



221 

223, 224 



CONTENTS. 



xiii 



Paragraph. 

various forms ; irregular ; regular ; sthenic ; asthenic ; chronic ; chalkstones 
of gout. 

255 Diabetes. Sugar traced to the blood; formed in the liver. Sugar often pre- 

sent in the urine of the aged and asthmatic. 

256 Treatment of gout and diabetes, compared and contrasted. Treatment of 

diabetes. Treatment of gout by alkaline eliminants. Cautions. Local 
treatment. Fit of gout. Gouty constitution. Gout in the stomach. 

257 Azoturia, or excess of urea. Result of decay of texture. Remedies: repose; 

stimulants; tonics; narcotics; tea and coffee. 

258 Fatty transformation in the blood ; impairing nutrition. Fatty degeneration. 

Section XVI. — Toxemia — Changed Properties of the Blood from the 
Presence of Foreign Noxious Matters . . 189 — 194 

259 The blood the seat of morbid poisons; and of the virus of malignant disease ; 

proofs. Examples of action of morbid poisons on the blood. Decomposing 
matter a nidus. Poisons of exanthemata ; of typhoid fever, &c. ; traced in 
operation, and with the reacting powers of the system causing the varieties 
of these diseases. 

260 Treatment indicated by the operation of the poison, and subsequent reaction. 

Remedies to counteract the poisons. To destroy or expel them. To re- 
gulate and sustain the functions. 



CHAPTER III.— PROXIMATE ELEMENTS OF DISEASE. 
Section L— Anemia ..... p. 195—206 
261 Explanation of proximate elements of disease. 

262 — 264 General angemia. Nature, exciting causes, and symptoms. Physical signs. 
265 — 267 Changes in the blood. Symptoms of excitement in angemia. Explanation 
268, 269 of these symptoms. Symptoms of coma, &c. Cases and interpretation of 
270, 271 nature of anaemic coma. Nutrition in angemia. Predominance of nervous 

272 symptoms. Fatal terminations. Extraordinary success of remedies in 
angemia. Iron and other tonics ; modes of exhibition. Regimen and diet. 
Treatment of nervous symptoms. Venous murmurs. 

273 Partial anaemia. Examples. Effects: cause of gangrene; numbness; 

wasting; degeneration. Treatment. General and Local. 

Section II. — Hyperemia or Excess of Blood . . p. 206 

274 Definition and nature. Classification of varieties. 

Section III. — Plethora — General Excess of Blood p. 206 — 211 

275 — 277 Origin of plethora. Subjects. Symptoms. Tendencies. Causes. Division 
278, 279 into Sthenic and Asthenic. Symptoms of Sthenic. Subjects. Tendencies. 
281 — 283 Asthenic. Symptoms. Subjects. Tendencies. Results. Fever. Gout. 
28± — 286 Remedial measures. Bloodletting ; where unfit. In sthenic, other mea- 
sures needed. In asthenic, tonics as well as evacuants and eliminants 
Diet and regimen. 



Xiv CONTEXTS. 

Paragraph. 

Local Hyperemia. Excess of Blood in 1 a tart. 
Section IV. — With Motion diminished. Congestion p. 211 — 229 

2S7, 288 Congestion analyzed. Its causes classed. 

289 Congestion from venous obstruction. Examples, in health and in disease. Ex- 

planation of congestion in emphysema. 

290 Congestion from atony of the vessels. From general debility. Hypostatic. 
291,292, From local debility ; over-distention. Examples. From intropulsive ac- 
293, 294 tion of cold and malaria, From over-excitement or inflammation. Exain- 
295, 296 pies and illustrations by microscope. Stagnation in the vessels. From 
298 arrest of secretion or capillary circulation. Explained by Mr. Graham's 



law of "Osmotic force." From imperfect respiration. (Is the power of 
the heart sufficient of itself to maintain the circulation? Dr. Sharpey's 
experiments. Microscopic examinations; fallacies. Objections to the 
supposition of spontaneous movement of the blood particles. Dr. Carpen- 
ter's assumption of the existence of a motory power in the capillaries con- 
sidered, and admitted as identical with Graham's "Osmotic force.") Ob- 
servations of Mr. Erichsen. Obstruction to circulation in asphyxia, partly 
from contraction of the small arteries, but also by suspension of osmotic 
299 force in capillaries. Atony of vessels also impedes transit of blood. Ex- 

300 — 302 periments to show the neutralization of force in the flaccid vessels. Cause 

of long continuance of congestion. 
303 Symptoms and effects of congestion. 1. In congested part — Impaired func- 

305, 306 tions. Effects on secretion explained. Production of flux. Examples. 

307 Considerable congestion required to produce dropsy. Amount of tension 

308 and quality of blood determine quality of effusion, liquid and solid. Ex- 
309, 310 amples. Albuminuria referred to congestion of the kidney. Reasons. 
311, 312 Congestion continuing causes hypertrophy of a peculiar kind. Origin of 

granular disease and cirrhosis. Other instances. 2. Effects of local con- 
gestion on the system. Fit of ague deprives it of blood. Examples. In- 
jury to blood. This congestion may cause cachsemia. 
313 Remedies for congestion. Removal of causes, venous obstruction and causes 

314, 315 of atony. Posture. Pressure. Friction. Exercise. Astringents and 
310,317 tonics; when applicable. Stimulant remedies; Operations shown by the 
31S microscope: when hurtful. Depletion and other evacuants. Hremostasis 

319, 320 or counter congestion. Preceding remedies combined or alternated. Pre- 
vention of congestions by increasing tone. 

Section V. — Local Hyperemia. Excess of Blood in a Part with Mo- 



tion increased. Determination of Blood . . p. 229 — 240 
321, 322 Examples in health and in disease. Determination to the head. Examples, 
324, 325 with symptoms. The cause of various fits. Determinations caused by 
326, 327 stimuli. Physical cause of determination of blood. Enlargement of ar- 
328, 329 teries, proved by the author's microscopic experiments. Observations of 

330 Mr. Paget and Mr. W. Jones. Cause of the enlargement, a loss of tonicity. 

331 Influence of the nerves on the arterial tonicity. Experiments of Bernard 

332 and W. Jones. Final cause of determination to supply more blood where 
wanted. Determination from intropulsion. Subjects of determination. 
Determination may cause anaemia in other parts. Determination affects 
any arteries. 

333 Symptoms and effects of determination of blood. Parts most subject to it. 



334 — 336 To the head. Explanation of its different effects in different cases. To 



CONTENTS. 



XV 



Paragraph. 



337 — 340 the kidneys. To the mucous membranes. To the skin. Other symp- 

341 toins. Determination if continued leads to hypertrophy. 

342, 343 Remedies. Removal of causes. Means which promote the tonic contrac- 

344, 345 tion of dilated arteries. Cold. Astringents. Sedatives which restore 

346 contraction of vessels. Derivants. Posture. Evacuants. Blood-letting; 

347, 34S general and local; its effect seen by the microscope. Cases requiring 

349 blood-letting. Remedies to relax the arterial system and quiet the heart. 
Measures to equalize and strengthen the circulation. Tonics. 

Section VI. — Results of Hyperemia .... p. 240 — 266 

350 Hemorrhage, flux, and dropsy, results short of inflammation. 

351 Hemorrhage from plethora. Examples. Epistaxis, haematemesis, &c, 

352 from congestion of venous obstruction. Examples. Pulmonary, bronchial, 

353 gastric, &c. From atony of vessels; from posture; from intropulsion of 
354, 355 cold. Examples. From determination of 'blood. Examples. Epistaxis; 
356 apoplexy; haematemesis. Additional element of hemorrhage in the vessels 
357, 358 or in the blood. Blood-vessels diseased. Examples. Blood diseased. 
359 Hemorrhagic diathesis. Mode in which blood is effused. By rupture or 

through the pores ? 

360, 361 Varieties of hemorrhage. Sthenic and asthenic defined. Symptoms. Mo- 
362 limen hemorrhagicum; jerking pulse, how produced. Faintness ; Reaction. 

363, 364 Transition to inflammation. Examples. Local effects and symptoms. 
365 Passive hemorrhage. 

366, 367 Treatment of hemorrhage. Remedies for hyperemia. Styptics. Cases re- 
368,369 quiring a speedy check. Active or sthenic. Passive or asthenic. Me- 
370 chanical means. Special styptics. Internal remedies. Tonics, purgatives, 

and styptics. Action of styptics considered. 
373 — 375 Flux and Dropsy. From -plethora. Examples. From congestion. Ex- 
periment of Lower. Examples in disease. 
376 — 37S From weakness of the vessels. After excitement. Intropulsion of cold. 
379 From determination of 'blood. Examples ; active flux; active dropsy. From 

stimulants. 

380 — 382 Flux and dropsy vicarious. Examples. Circumstances causing hyperemia 
3S3 to end in these results: in the vessels : in the blood. Combination of these 

384 circumstances in anaemia. Diseased blood from defective excretion, espe- 

cially by the kidneys. Examples and proofs. Cause of anasarca after 
3S5 scarlatina. Changes in the kidneys. Dropsy and flux with albuminuria : 

386 why inflammatory: resemblance to rheumatism. Thinness of blood, cause 

337 of asthenic dropsy. Dropsy from retention of water and excrementitious 

388 matter in the blood. Malnutrition. Proofs. Distinctive pathology of 

383 fluxes and dropsy. Causes of each. 

390 General treatment of ' flnx and dropsy . Remedies for hyperemia. Remedies 

391 for malexcretion and malnutrition. 

392, 393 Treatment of faxes. Removal of causes. Derivants. For sthenic flux ; 

394 evacuants and depletion; not to be hastily checked. For asthenic flux; 
astringents and tonics. Dry and tonic regimen. 

395 Treatment of dropsy. Means to remove effusion and restore action of kid- 
396, 337 neys in sthenic dropsy. Means to improve the blood in asthenic. Re- 
398 currence of dropsy requires variation of remedies. Circumstances which 

indicate tapping or puncture. Cautions. Means to prevent recurrence of 
dropsy. Pressure. Injection of iodine. 



Xvi CONTENTS. 



Section VII. — Local Hyperemia. Excess of Blood in a part, with 
Motion partly increased, partly diminished — Inflammation 

p. 266—352 

Faragrapli. 



399, 4U0 Inflammation not understood from its elements not being studied. Defini- 

tion according to its nature; according to its signs. 

401 Causes of Inflammation and their Mode of Operation. Predisposing; 

weakness, or excitement. Exciting causes divided into local and general ; 

402 direct and indirect. Local irritants; mechanical, chemical, and vital. 
4 03 Examples. Poisons and other irritants in the blood. Predisposition to 
404 catarrhs. Indirect causes produce congestion. Causes mixed in opera- 

400, 406 tion. Checked hemorrhage and flux. Irritants operate primarily on the 

407 nerves. But inflammation is excited without nervous irritation, and when 

408 nerves are divided. Cause essentially acts on vessels, producing some- 
times determination first, sometimes congestion. 

409 Phenomena and Nature of Inflammation. Difference from congestion ; 

410 from determination. Essential characters established; increase of blood, 

411 with motion increased and diminished. Cause of the obstruction. Views 

412 of Cullen, W. Phillip, Hunter, Kaltenbrunner, and Alison, considered. 

413 Existence of congestion and determination proved. Atony of the vessels 

414 one cause of obstruction. Examples and experiments. Another cause of 

415 the blood: adhesion of white globules; their increase. Description and 

416 production of white globules; Mr. Addison's observations; Mr. Gulliver's. 
Appearance of frog's web after irritation. Adhesive property of white glo- 

417 bules ; those recently formed have no cell-wall. The presence and proper- 

418 ties of white globules essential to inflammation. Variation in the osmotic 
force of the capillaries. Share which the red corpuscles take in the ob- 
struction, questioned by Dr. Hughes Bennet, and Mr. Paget: affirmed by 

419, 420 Mr. Gulliver. Conclusions as to the process of inflammation ; essentially 

421 complex. Effect of obstruction to expend force on the arterial capillaries, 
and to modify the osmotic force and composition of the blood. This oppo- 
sition of obstruction to force the cause, both of construction and of destruc- 
tion of blood and tissue material. 

422 Effects of inflammation on vital properties ; on secretions. 

423 Effusions; liquid; solid; general character ; microscopic character. Exuda- 

424 tion corpuscles. Elementary solids of inflammatory effusions. Molecules. 

420, 426 Granules. Fibrils. Exudation corpuscles. Pus globules. Irregular pro- 

ducts. Tubercle. Mode of formation of some of these. Variety in their 

427 plasticity and organizability. Other effects of inflammation. Softening. 
Suppuration. Slough. Gangrene. Induration. 

428 Symptoms and Effects of Inflammation. Divided into local and general. 

429, 430 Local symptoms. "Redness; causes; varieties; changes; explained and ap- 
431, 432 plied. Heat; cause; indications. Swelling; causes; varieties from tex- 
433, 434 ture ; position, &c. Pain; causes. Degrees and varieties and their causes. 

430, 436 Other sensations. Effects of inflammation on contractility. On other 

functions and symptoms. 
437 Constitutional symptoms. Inflammatory fever. Change in the blood. 

438, 439 Cause of the increase of the fibrin and its contractile property. This not 

the sole cause of inflammatory fever. Pathology of inflammatory fever. 
440, 441 Causes. Reaction, irritation, altered condition of the blood. Why some 

442 functions are excited and others impaired. Symptoms of inflammatory 

443 fever. Its varieties: high, low. Type of fever from cause or seat of in- 



CONTENTS. 



xvii 



Paragraph. 

444 flammation. Explanation of this. Remittent and intermittent fever. 

Apyrexia. Injury to blood in continued inflammation. 

Nature and Symptoms of the Results or Terminations of Inflammation. 

445,446 Division. The results seldom occur singly. Resolution. Its nature. 

447,448 Modes of occurrence. Local symptoms. Constitutional symptoms of reso- 
lution. Critical discharges. Lateritious sediments in urine; cause; nature: 
reason of absence; reappearance of chlorides. 

449 Tffnsion (including adhesion.) Not always a termination. History of ef- 

450 fusions in serous membranes. Coagulable lymph. Varieties. Euplastic. 

451 Mode of organization. Formation of vessels. Views of Kiernan, Travers, 
452,4."3 Vogel, Liston. Cacoplastic lymph; corpuscular; (Paget) croupous (Ro- 
454,455 kitansky.) Varieties and effects. Aplastic lymph. Causes of these low 
456 products. Effusions of mucous membranes. Interstitial deposit. Changes 
457,458 of mucus; purulent and fibrinous; stricture. Effusion in shin; varieties 

of cutaneous inflammation exemplified in skin diseases. Effusion in cellu- 

459 I ar texture. In parencltymata. Symptoms of effusion. 

460 Suppuration and ulceration. Nature of pus. Microscopical characters. 

Distinction between exudation corpuscles and pus. Alteration by acetic 

461 acid; by distilled water. ■ Its want of cohesion. Explanation of this. 

462 Liquefaction of tissues in suppuration. Chemical changes. Causes of 
suppuration. Circumstances tending to the conversion of the deutoxide of 
protein into the tritoxide. 1. Intensity and continuance of inflammation. 
2. Access of air. 3. State of the blood; suppurative diathesis. Examples. 

463 Mode in which they act. Observations of Mr. Paget. Pus in the blood. 
Process of suppuration explained; death of tissue by pressure; liquefaction 
and absorption of all but pus globules. Varieties of suppuration. Dif- 

464 fused; Abscess: pyogenic membrane: pointing. Opening and healing of 
465, 463 abscesses. Granulations. Ulceration. Varieties. Causes. Softening 
467 of textures. Suppuration a work of destruction, therefore depressing. 
468, 469 Symptoms of suppuration. Local : constitutional : varieties caused by limi- 

470 tation, or not, of suppuration. Purulent deposits. Nature and causes. 
No true absorption of pus. Pus frequently in the blood in severe inflam- 
mation. Cachaemia usually precedes pyaemia. Depression from suppura- 

471 tion. Cause of rigors. Hectic fever. Varieties of pus; laudable; ill-con- 
ditioned. 

473,474 Gangrene. Process of sloughing; gangrene; and sphacelus. Causes of 

475 gangrene; interrupted circulation ; noxious agents. Local symptoms and 

476 effects of gangrene. Varieties. Constitutional symptoms. Combinations 
and gradations of the results of inflammation. 

Varieties of Inflammation. 
477,478 Sthenic and asthenic; symptoms and results. Acute inflammation generally 

479 sthenic; symptoms, duration, products. Subacute. Chronic; generally 
asthenic; symptoms, duration, results. Cause of their variety. 

480 Congestive inflammation ; nature, symptoms, results. 

481 Phlegmonous inflammation ; nature; causes; type and symptoms. 

482 Eryihematic and erysipelatous; local symptoms and effects; fever; cause 

483 specific. Pyaemia. Pellicular; asthenic; symptoms; low fever. Plas- 
tic inflammation of mucous membranes. Aphthae of adults often attended 

484 by the growth of a confervoid vegetable. Aphthae of children. Hemor- 
rhagic inflammation; causes. 



XV111 



CONTEXTS. 



Paragraph. 



4d5 Scrofulous inflammation; asthenic: peculiar symptoms. Microscopic cha- 

racters of scrofulous matter. Changes which it undergoes. Scrofulous 
abscesses. Scrofulous diathesis ; its external marks ; symptoms and causes. 
Course and results of inflammation in scrofulous subjects in various tex- 

4SG tures. Condition of the blood. Gouty and rheumatic inflammations. Na- 

ture and causes. Gonorrheal inflammation; seat and effects. Syphilitic 

487 inflammation; seat and effects. 

488 Treatment of inflammation, best understood from knowledge of its ele- 

ments and of their counteracting measures. 
4S9 Tabular view of constituents of inflammation. 

490 Tabular view of the chief elements of inflammatory disease, and their reme- 

491 dies. Comments on these principles of treatment. Remedies for incipient 

492 inflammation: 1. for congestion ; 2, and 3. for irritation of nerves and ves- 

493 sets. Remedies for established local inflammation; 4. for determination 

494 to the part; 5 and 6. for obstruction in the part from atonic enlargement 
of the capillaries, and by adhesion of the white particles with accumulation 

495 and impaction of the red ones; 7. Distention of vessels; 8. for effusions 
496, 497 from the vessels; 9. for increased absorption; 10. for impeded circulation 
498, 499 in the part; 11. for increased circulation around the obstructed part. 

500 Treatment of inflammation with fever. Local remedies secondary. Chief 

501 remedies, general bloodletting ; effect. Tolerance of bloodletting; cause. 
502, 503 Dr. M. Hall's scale of tolerance. Objects and mode of bloodletting; in 

recent inflammation; in confirmed inflammation; in inflammation with 
plethora; in anaemic subjects; substitutes. Local bloodletting; uses. Re- 
•304 cent disuse of bloodletting. Evacuants; purgatives ; combinations. Tar- 

505, 506 tarized antimony ; modes of administration ; modes of operation. Mercury. 
507 Calomel and opium; modes of exhibition ; modes of operation. Refrige- 

508, 509 rants. Salines. Sedatives. Diuretics. Counter-irritation. Antiphlo- 
510,511 gistic regimen and diet. 16. Exhaustion. 17. Depression from poison. 

512 Remedies : their mode of. action Stimulants, antiseptics, tonics, &c. IS. 
Treatment for products of inflammation, liquid and solid; iodine; nitric 
acid; cod liver oil. 

Treatment of Varieties of Inflammation. 

513 — 516 Sthenic. Asthenic. Acute. Subacute. Chronic. Congestive. Phlegmo- 
517 — 519 nous. Erysipelatous. Pellicular. Hemorrhagic. Scrofulous. Treat- 
520, 521 ment of the scrofulous diathesis and deposits. Cod liver oil. Rheumatic 

and gouty. Gonorrhoea! and syphilitic. • 



CHAPTER IV.— STRUCTURAL DISEASES; OR DISEASES OF NUTRITION. 

Section I. — Nature and Classification . . . . p. 353 — 357 

522 Arrangement of structural diseases. Table of elements. Structural disease 

523 often complicated. Objects and mode of natural nutrition. Blood forma- 

524 tion. Materials of nutrition, derived from the blood; changes in which 
cause variations in nutrition. Relation of nutrition to nervous influence. 



CONTENTS. 



xix 



Section II. — Increased Nutrition — Hytertrophy . . p. 357 — 359 

Paragraph. 

525 — 527 Affects textures, or organs. Simple hypertrophy; of muscles; examples, of 
52S filamentous interstitial tissue; of epidermis; varieties in skin diseases. 

Complex hypertrophy; uterus; breasts; brain; follicles; bursa?, &c; liver 
523 and spleen. Treatment of hypertrophy. That of the heart curable. 

Section III. — Diminished Nutrition — Atrophy . . p. 360—363 

General emaciation. Causes : divided into those which promote decay and 
those which prevent nutrition, examples of each. Cause of emaciation in 
531 fevers. Views of Dr. Hodgkin; Rokitansky. Drains from the body. 

Series of causes which prevent reparatory nutrition. When traced to its 

533 cause, general atrophy an important sign. Partial atrophy from defective 
supply of blood. Examples. Treatment of general atrophy; according 

534 to its cause ; nutrients and aids to nutrition. Treatment of partial atrophy. 

Perverted Nutrition. 

535 Alterations of texture in kind. 

Section IV. — Induration and Softening . . p. 363 — 366 

536 Both may result from inflammation, or occur independently. Nature of indu- 

537 ration. Often accompanied by transformation of tissues or interstitial de- 
posit. Examples. 

538 Softening. Specific causes. Common causes. Partial softening; nature. 

539 From obstruction of vessels. Examples. From antiphlogistic treatment. 
540, 541 Treatment of induration and softening, opposite but parallel. Treatment 

of softening generally tonic and supporting. Action of nitric acid, and 
other oxydizing agents. Specific causes. Treatment of mollities ossium. 

Section V. — Transformation and Degeneration of 

Textures . . . . . p. 367 — 375 

542 Transformations generally degenerations. Exceptions: skin and mucous 

543 membrane. Transformation of muscle. Four kinds of progressive dege- 
neration : Fibrous, granular, fatty , and osseous, or calcareous. Fibrous, re- 
sembles fibrous tissue but apt to degenerate further. Muscles and paren- 
chymatous organs exhibit this change, sometimes owing to interstitial de- 

544 posit. Granular, a cacoplastic interstitial deposit or transformation; in- 
vades morbid as well as natural fibrous tissues, and may degenerate farther. 

545 Fatty degeneration ; fat formed in the proper tissue of the parts, muscular, 
fibrous, and cellular; observations of Gulliver, Quain, Paget and Canton. 
Fatty liver; appearance; subjects; cause. General fatty degeneration: 
subjects of it. Dr. George Johnson's views of Bright's kidney. Other 
examples of fatty transformation. Observations of Mr. Gulliver and Dr. 
Davy. A chemical process like the formation of adipocire proved by Dr. 
Quain's experiments. Circumstances disposing to the general disorder; 
as affecting particular organs; often preceded by a cacoplastic deposit; 
always indicates a degradation of material. Analogy to vegetable matter. 
Effects. Examples. 

546 Calcareous degetieration ; tissues most liable to it; a chemical process or pe- 

trifaction; manner in which this occurs ; produced spontaneously in old age, 

547 or as a result of inflammation. Effects. Treatment of degenerations. 
Means of sustaining vital powers. Hygienic measures. Tonics. Altera- 
tives. Mineral waters. Removal of local disorders. 

Treatment of fibrous and granular degeneration; of fatty; of calcareous. 



XX CONTENTS. 

Section VI. — Deposits in or upon Textures . . p. 376 

Paragraph. 

548 Definition of deposits. Nature. Division into euplastic, cacoplastic, and 

aplastic. 

549 Euplastic deposits. Cicatrices. Reparation effected by four modes : imme- 

diate union of Dr. Macartney; union by first intention; by new tissue; by 
suppurative granulations. Drs. Macartney and Carpenter's account of tiie 
organization of cicatrices. Observations of Paget. Reparation by lymph ; 
551 by suppurative granulations. Modelling process of Macartney. Repara- 

tion by blood. Vascularity of clots. Remedial measures to promote 
healing of wounds, &c. 

553 Cacoplastic and aplastic deposits. Examples of the former: structure; 

554 causes, general and local. Cirrhosis. Granular degeneration. Structure. 

555 Semi-transparent, gray, and tough tubercle: a degraded kind of lymph. 

556 Observations of Gulliver, Addison, Rokitansky, Mandl, &c. Connexion 
with other cacoplastic deposits. Tendency of cacoplastic deposits to con- 
traction. Farther history shown by examples; effects; intimate nature ; 

557 reason of granular forms. Degeneration into aplastic, the common ten- 
dency of tubercle, analogous to fibrous and granular and fatty degeneration. 

558 Form of tubercle. Causes. Microscopical and chemical character of gra- 
nular tubercle. Opaque change indicates aplastic degeneration; causes of 

559 this change. Primary aplastic deposits; proof of degraded nutrition; yel- 
low tubercle, maturation and softening : the converse of contraction. In- 

560 crease of fat in softened tubercle, and its analogy to fatty degeneration in 
general. Softening of tubercle attended by the formation of a material offen- 
sive to the system. Changes of tubercle from adjoining textures. Quies- 
cence of tubercle ; spontaneous changes, withering ; blackening ; induration ; 

561 plastery and petrifactive change, absorption of tuberculous matter. Causes 

562 of cacoplastic and aplastic deposits; congestion; chronic and asthenic in- 
flammation; degraded plasma of the blood with defect of red particles. 

563 Seat of tubercles. Reasons of the liability of the lungs considered. Re- 

564 lation of tubercles to venosity of blood. External or exciting causes of tu- 
bercles; operation explained. 

565 Treatment of cacoplastic and aplastic deposits. Elements to be considered. 

1. Disordered condition of the blood and its causes. Cachaemia great where 
deposits general. . Remedial measures. Supply of better materials of 
blood, and removal of those depraved. 

2. Disordered distribution of blood and its causes. Various kinds of hype- 
rasmia. Remedial and preventive measures. 

567 3. Deposits already present ; their effects and changes. Medicine of little 

power; why? Mercury; alkalies; iodine and iodides ; tonics ; iron. Sol- 

568 vents? caustic alkalies, acetic acid, naphtha, fixed oils. Cod liver oil. 
Theory of its beneficial operation, not from its iodine, &c, but as an oil. 
Confirmation of its efficacy; doubles the duration of life in phthisis. Best 
kind of oil, the freshest and sweetest; results of its use in nearly 9000 
cases. Objection to the brown oils. Best mode of preparing the oil, and 
cautions. Objection to external use. Directions in the use of the oil. 
1, selection; 2, mode of exhibition; 3, time of exhibition; diet, &c. Im- 
portance of other hygienic means. Improvement of the circulation. 
Means which promote absorption and oxidation. 



566 



CONTENTS. 



xxi 



Paragraph . 

Section VII. — Morbid Growths .... p. 403 

569 Definition. Names and divisions. Analogous and heterologous, &c. 

Section VIII. — Non-malignant Growths ... p. 404—410 

570,571 Definition. Serous cysts. Distinguished from enlarged natural sacs. En- 
512 cysted tumours. Hygroma. Hasmatoma. Steatoma. Atheroma. For- 

573 mation of these. Contents. Complex cystiform tumours. Sarcoma. 
Fibrous. Adipose. Chondroma. Erectile tumour. Dr. Hodgkin's view 

574 of the cystiform origin of tumours. Pathological cause of morbid growths : 

575 altered vital property of constituent cells ; where most altered most in- 

576 jurious. Hydatids. Proofs of separate vitality ; nature and origin; re- 
production; Mr. Owen's description. Offsets of natural tissues. Situa- 
tions. Death; aplastic and fatty deposits around them. Echinococcus. 

577, 578 Cysticercus. Distoma. Medical treatment of morbid growths, and their 
effects. Extirpation of cysts by iodine. 

Section IX. — Malignant Growths . . « p. 410—420 

Definition. Characters of malignancy; varies in degree. 
Cancer or Carcinoma the generic term. Enumeration of species. Varieties 
traced to different degrees of activity of cancerous matter. Some acute, 
some chronic. Elementary structures of cancer : cells, forming fibres, &c. 
Varieties. Disposition to grow at expense of nutrition of the body. Pa- 
rasitic nature ? germs or ova. Experiments of Langenbeck. Local origin 
of cancer as a modification of nutrition. Dr. Hodgkin's view. Practical 
deductions from pathology of cancer. Mode of origin. Cancer contrasted 
with tubercle. Microscopic diagnosis of cancers; often uncertain, yet mi- 
croscopic characters instructive. Varieties of cancer explained by differ- 
ence in quantity and fertility of germs ; and activity of nutrition in adjoin- 
ing textures. Scirrhus is the chronic form. Symptoms; tendencies. 
Open cancer : destructive effects on part, and wasting influence on whole 
frame. Epithelial cancer; peculiarities. Pancreatic, mammary , larda- 
ceous, and solanoid, intermediate forms of cancer. Mode of growth. En- 
cephaloid cancer the acute variety; in parts and subjects where nutrition 
is active. Cause of rapid growth of encephaloid disease. Colloid cancer, 
the cancerous element in a separate form. Other varieties from form, &c. 
Melanosis, black cancer. Varieties. Peculiar black matter, its nature. 
Pigment cells. Altered blood corpuscles. May occur apart from ma- 
lignant disease. Mr. Paget's remarks. Bronzing of skin. 
Treatment of malignant growths. Indications. 1. To extirpate them; 2. 
To retard their development; 3. To counteract their effects. Means of 
attempting the fulfilment of these. 

Section X. — Disorders of Mechanism . . . .p. 421 

591 Changes in mechanism, elements of disease. Examples. 

592—594 Dilatation; Contraction. Rupture and laceration. Displacement and com- 
pression. Contortion. 



579 
580 
581 
582 



583 



584 

535 
586 

587 



588 



>, 590 



xxii 



CONTENTS. 



CHAPTER V— CLASSIFICATION, SYMPTOMS, AND DISTINCTION OF 

DISEASES. 

Section I.— Nosology . . . . p. 422—424 

Paragraph. 



596 Definition of special diseases. Methods of classification. 

597 Symptomatic. Methods of Sauvage, Cullen, &c. Correct pathology the 
538,593 true foundation of natural classification. Method of Pinel. Classification 

of diseases with reference to pathology. Examples of pathological classi- 
600 fications. Why preferable. Pathological definitions of disease. 

Section II. — Semeiology and Diagnosis . . .p. 425 — 435 

001, 602 Definition of symptoms and signs. Physical signs. Examples. Those of 
disease known by comparison with healthy standards. Standard of sym- 
603, 604 metry. Anatomical standard. Physical signs explained by physical laws. 
605, 606 Vital symptoms. Called also functional and physiological, general and 
607 rational. Examples. Sources of symptoms. Pulse. Skin. Tongue. 

608, 609 Stools. Urine. Knowledge of pathology the best key to symptoms. Sta- 
610 tistics an imperfect and temporary substitute. Respective value of phy- 

sical signs and vital symptoms: examples. Division and nomenclature of 
symptoms. 

611,612 Diagnosis defined. How founded. Division into general and special. Dia- 
613, 614 gnosis, illustrated by problems, and modes of solution. Need of every 
615 branch of medicine in diagnosis. The test of ability and knowledge. Ob- 

jects of examination with regard to diagnosis, prognosis, and practice. 



CHAPTER VI. — PROGNOSIS. FOREKNOWLEDGE OF RESULTS OF 

DISEASE ... p. 436—452 

616 Definition. Prognosis, empirical or rational: Empirical that of infant me- 

617 dicine. Prognostics of Hippocrates. Good and bad signs. Rational pro- 
6 IS gnosis described and exemplified. Circumstances from which prognosis 

619 may be formed, 1. relating to the subject ; 2. to the disease; 1. Age of the 
subject; sex; temperament: previous diseases; present diseases; previous 
habits; condition of the patient at the time of the attack. 

620 2. Of the disease. The cause, situation and nature, extent and progress; the 
621, 622 character of the symptoms. Good symptoms. Bad symptoms, signs of 

impediment to a vital function, and approach of one of the modes of death. 
Operation of all the modes of death on the blood, proved. Modes of death 
arranged in table. 

625 Death by Syncope. By spasm of the heart. Causes: examples. By loss of 

irritability: causes; poisons; diseases; symptoms of approach. 

625 Death by Asthenia. Gradual failure of the circulation. From diseases ; 

symptoms of approach. 

627 Death by Asphyxia. Distinction. Symptoms. Causes. Varieties in re- 

lation to prognosis. 

623 Death by Coma. Causes: symptoms. Combined with excitement of the 

medulla. How does coma cause death? By abolishing supplementary 
voluntary breathing. Stenor. Medullary symptoms the most serious, 
and induced where coma is profound. 



CONTENTS. 



xxiii 



Paragraph. 

629 — 631 Death by Paralysis. Injuries to the medulla, to the afferent nerves of re- 
spiration, to the efferent nerves. Examples. Paralysis of spinal nerves 

632 with and without injury to the cord. With injury of cord itself, symp- 
toms and fatal tendencies. 

633 Death by Necrcsmia. Explanation. Proofs of death of the blood. Mode 

634 of spreading death to other parts. External causes of necroemia. Vital 
resistance to its causes. Symptoms. 

635 Modes of elimination of causes of necrsemia. Intrinsic causes of neersemia. 
636 — 638 Symptoms of death by necrsemia. Slow deaths, more general. 



CHAPTER VII.— PROPHYLAXIS AND HYGIENICS, p. 453— 4S6 

639 Definitions. Prophylaxis connected with special pathology. Hygienics refer 

640 to means of resisting disease generally, and to means which maintain the 
general health. Subjects for consideration enumerated. 

641, 642 Food. Purposes of; essentials of wholesome food. Wheat en bread; unfer- 
mented bread. Meat: use and abuse of cooking. Varieties of meat, their 
constituents and wholesomeness. Fish, poultry, &c; broths and soups: 

643 eggs and milk; cheese. Vegetables. Choice of food and hours of meals. 

644 Breakfast and luncheon, dinner, tea, supper. Adaptation of meals to habits. 
Regularity in the hours of meals. Injury from long fasting. 

645 Clothing. Purposes. Provisions for alteration in the covering of the lower 

646 animals; according to season, weather, and temperature. Materials of 

647 dress. Objects in selecting them. To protect from cold; from currents 

648 of air; from dampness and dryness. Cautions in changing winter for sum- 
649, 650 mer clothing. Summer clothing. Silk vestments, electric influence. 

651 Cases requiring additional warm clothing. Coverings for the head. Va- 
rious cautions. 

652 Air a.nd temperature. Beneficial effects of pure air ; of change of air, seaside 

653 and inland. Travelling: high winds. Dry air ; its ill effects; modes of 
preventing them; causes.; soil; winds. East-wind. Ozone. The sirocco; 

654 effects. Damp air. Effects. Mode of operation. Cold and damp air; 
morbid effects. Causes of damp air; winds, soil, dwellings. Marine hu- 

635 midity. Protective and counteractive means. Temperature; average 

most healthy. Causes of the oppressiveness of heated rooms. Salutary 

656 influence of cool air. Cases requiring additional warmth. Mr. Jeffery's 
respirator. 

657 Ventilation. Modes of ventilating in winter and summer. Dr. Arnott's 
658, 659 principles and contrivances. Haden's plan of ventilating the Brompton 

Hospital. Supply of warm air. Forces used in ventilation. Means and 
agents for purifying air. 
660, 661 Bodily exercise. Beneficial effects of moderate exercise. Directions and 

662 cautions regarding exercise, according to age, strength, occupation, &c. 
Times for taking exercise. 

663, 664 Caution as to amount and kinds of exercise, and their effects considered. 
665 Mental occupation. Moderate and equal exercise of mental faculties bene- 

666, 667 ficial. Adaptation to age; in infancy; mental education and discipline; 

663 • in youth; in maturity. Body and mind to be equally exercised; evil re- 
669 suits of neglecting, and good effects of observing, this rule. Variation of 

occupation invigorates the mind. 



XXIV 



CONTENTS. 



Paragraph. 



670 Sleep. Effects and nature of healthy sleep. Symptoms: gaping ana yawn- 

671, 672 ing. Circumstances which promote sleep: those which prevent or disturb 

673 it; nightmare. Evil consequences of want of sleep. Directions to bad 
sleepers. Means of inducing sleep: Mr. Gardner's; the author's; Dr. 

674 Franklin's, &c. Reasons of their failure. Amount of sleep proper ; varies 
67-5 with age, sex, strength, occupation, &c. Sleep to be limited, especially 

in certain cases. 

676 Excretion. A proper subject for hygienic rules; depends on due activity of 

677 many functions. Intestinal excretion. Importance of punctuality and 

678 time for its evacuation. Various aids; in diet, exercise; by habitual ape- 

679 rients; their safety and efficacy when needed. 

680 Urinary Excretion ; its importance. Amount and quality varies with diet, 

exercise, &c. Cold water and other diuretic drinks. Propriety of timely 

681 but not too frequent evacuation. Excretions of the skin not fully known; 

682 objects specified, promoted by various hygienic means, and specially by 
bathing, washing, and friction: operation and useful application of these. 
Vapour and shampooing bath. 



PRINCIPLES OF MEDICINE. 



EXPLANATION OF THE OBJECT OF THE WORK. 



1. The Principles, Elements, or Institutes oe Medicine con- 
sist of those leading and general facts and doctrines regarding disease 
and its treatment, which are applicable, not to individual cases only, 
but to groups or classes of diseases. The same branch of medical 
knowledge is also designated by the term General Pathology and 
Therapeutics, to distinguish it from Special Pathology and Thera- 
peutics, or the theory and practice of medicine in relation to individual 
diseases. 

2. The principles of medicine may be deduced in part from a know- 
ledge of the animal structure and its functions (anatomy and physio- 
logy,) conjoined with an acquaintance with the agents which cause and 
remove disease; they are chiefly arrived at by a generalization of the 
facts observed in an extensive study of disease itself, whether these be 
effects manifested in the living or in the dead body. But so far as 
they have been ascertained, they become more intelligible to the stu- 
dent if explained synthetically, that is, by describing first the causes 
of disease, then the operation of these on the body, and lastly, the re- 
sulting changes in function or structure which constitute the more ele- 
mentary forms of disease. 

3. Etiology, or a knowledge of the causes oe disease, appro- 
priately introduces the consideration of the effect — disease itself ; the 
nature and constitution of which may then be conveniently considered 
under the head of pathogeny, or pathology proper. This last sub- 
ject is the one to which I design to chiefly direct attention, and there- 
fore, it will occupy the greater part of the work; but it will be also 
combined with such an elementary view of the principles of treatment 
(general therapeutics,) as reason and experience may supply. 

4. A short general view will afterwards be given of the phenomena 
of disease (semeiology,) — of the division and classification of diseases 
(nosology,) — of their detection and distinction from each other (diag- 
nosis,) — of the indications of their probable results (prognosis,) — and. 
of their prevention (prophylaxis and hygienics.) 



34 



DEFINITION OF DISEASE. 



DEFINITION OF DISEASE. 

5. The reader is presumed to be acquainted with anatomy and phy- 
siology: without such knowledge not even a definition of disease can 
be formed. Disease is known only by comparing it with the standard 
of health, which it is the object of anatomy and physiology to describe. 

Health consists in a natural and proper condition and proportion in 
the functions and structures of the several parts of which the body is 
composed. From physiology we learn that there are certain relations 
of these functions and structures to each other, and to external agents, 
which are most conducive to their well-being and permanency; these 
constitute the condition of health. But this knowledge implies that 
function and structure may be in states not conducive to permanency 
and well-being: states which are deviations from the due balance be- 
tween the several properties or parts of the animal frame ; these states 
constitute disease. For example, physiology, as well as experience, 
teaches us, that in health the digestion of food is easily performed and 
attended by sensations of comfort. But when, after food is taken, 
there is pain, uneasiness, sickness, eructation, flatulence, or the like, 
we know that the function of digestion is changed from the healthy 
standard — is diseased; and if this diseased function continue long in 
spite of the employment of remedies which usually serve to correct it, 
and if on examining the abdomen we find at or near the epigastrium a 
hard tumour, which anatomy teaches us is not there in health, we know 
that there is also diseased structure. 

6. We find, then (§ 5,) that in this case there is disease of function, 
known by its deviation from a standard furnished by physiology ; and 
also disease of structure, which is recognised by departure from a stan- 
dard supplied by anatomy, (§ 5.) These different kinds of disease may 
be, and very commonly are, combined: there is seldom structural dis- 
ease without some disorder of function ; and in many instances func- 
tional disease is, or ultimately will be, accompanied by change of 
structure. 

7. Looking, then, to anatomy and physiology as expressing the 
standard of health, we may define disease to be, a changed condition 
or proportion of function or structure in one or more farts of the body. 

8. The standard of health is not, however, the same in all indivi- 
duals : that which is health to one may be disease to another. Thus 
to instance individual functions : — The healthy pulse in adults ave- 
rages from 70 to 80 ; yet there are some in whom 90 or 100 is a healthy 
pulse. Some persons fatten on a quantity of food on which others 
would starve. Muscular strength and activity, nervous sensibility, 
and the sensorial powers, vary exceedingly in different individuals, yet 
all within the limits of health: what is health in one would be deci- 
dedly morbid in another. Unusual proportions of the different struc- 
tures or functions to each other constitute varieties of temperament; 
and although these can scarcely be called morbid, yet they certainly 
give, as we shall afterwards see, a proclivity to disease. Thus pre- 



STANDARD OF HEALTH VARIABLE. 



35 



dominance of sensibility and excitability of the excito-motory nerves 
over other vital functions, constitutes the nervous temperament, which 
is compatible with perfect health, although it predisposes the individual 
to diseases of a nervous kind. A preponderance of the nutritive func- 
tions renders a person florid and bulky, although in perfect health ; 
but this carries with it a risk of exceeding the bounds of health, and 
of inducing plethora and obesity, to such an extent as to interfere with 
the well-being and order of the bodily functions, and so to constitute 
disease. 



CHAPTER I. 

ETIOLOGY — THE CAUSES OF DISEASE. 



SECTION I. 
NATURE AND DIVISION OF CAUSES. 

9. Causes of disease are such circumstances as essentially precede 
it, and to whose operation its occurrence is due. In many instances 
these circumstances elude our observation. In many others, the true 
cause, if apparent, is combined with other circumstances which have 
no share in producing the result, disease, and which yet are thence 
liable to be mistaken for causes. These circumstances are to be sifted, 
and the true cause discovered, only by the attentive observation of 
large numbers of cases, in which disease is produced. The non-essen- 
tial circumstances will then be found to be sometimes absent, and that 
which is always present may consequently be fairly regarded as the 
influential cause. But this, as before stated, sometimes eludes obser- 
vation; in this case, as well as in elucidating the operation of circum- 
stances supposed to act as causes, the most useful knowledge may be 
obtained by investigating the ultimate nature of the disease itself, 
which will often throw light on its own source. Thus it was at one 
time a matter of doubt whether the itch could be engendered from filth, 
as well as from contagion ; but since microscopic investigation has dis- 
covered the existence of the itch-mite, no doubt remains that this in- 
sect is the only essential cause of the disease, however its operation 
may be promoted by filthy habits. 

10. The causes, or circumstances, inducing disease, may be intrinsic, 
or existing within the body, independently of any obvious external in- 
fluence ; or they may be extrinsic, having their origin without the body. 
As examples of intrinsic causes may be mentioned excess or defect of 
some function (such as irritability,) or of some constituent of the body 
(such as the blood.) Extrinsic causes are very numerous ; they com- 
prise indeed all the external agencies which can operate on the body 
or mind, such as temperature, air, moisture, food, poisons, mechanical 
and chemical influences, and sensual impressions. 

11. A great variety of agents and circumstances may thus act on 
the body so as to produce disease ; but in most instances it seems as if 
there were not that uniform and constant relation between these causes, 
and the diseases that result, which we might expect from the analogy 



UNCERTAINTY OF OPERATION. 



37 



of the operation of causation in the simpler sciences. In chemistry or 
in mechanics obvious effects certainly and uniformly follow obvious 
causes ; in physiology or pathology, no doubt, certain fixed effects also 
follow certain determinate causes; but whether these effects become 
manifest as disease or not, depends on many circumstances, of which 
often we can take no cognizance. When the causes are of the same 
nature as those which are operative in physics or chemistry, the ex- 
pected effects never fail to ensue. Thus, a cutting instrument, a red- 
hot iron, or a corrosive liquid, invariably produces disease, when ap- 
plied, because its physical or chemical operation is so energetic that 
it overcomes all vital properties. Certain poisons and other analo- 
gous potent agents, which act on, without destroying, the vital pro- 
perties of living parts, also, if of sufficient strength, pretty constantly 
produce morbid effects. Thus, opium taken internally causes somno- 
lency; tartar emetic excites nausea and vomiting; cantharides applied 
to the surface induce inflammation, &c. 

12. But the most common causes of disease are seldom of this de- 
cided and positive character; they are often present without disease en- 
suing ; and they are known to be causes only because disease is ob- 
served to ensue in a greater number of cases when they are present, 
than when they are absent. Thus, improper food is a cause of indiges- 
tion, and exposure to cold is a cause of catarrh ; yet many persons eat 
unwholesome food without suffering from indigestion, and many are 
exposed to cold without "taking cold." But those, who do suffer from 
indigestion, observe that they do so more certainly after taking impro- 
per food ; and those who are affected with catarrh can often trace it to 
exposure to cold. The reason for this uncertainty of action is chiefly 
found in the difference of power which the body exerts in resisting the 
morbific influence; this power varies much under different circum- 
stances. Its failure, or irregular operation, constitutes a predisposi- 
tion to disease. 

13. Causes of disease were formerly divided into remote and proxi- 
mate: the remote include predisposing and exciting causes, the only 
circumstances now considered as causes. They were called remote, 
not because they are distant or not in the body, but because they are 
not, like the proximate cause, a constant and present part of the dis- 
ease. The term proximate cause was used by Cullen (after Graubius) 
to represent the pathological condition, or essential bodily change, on 
which the symptoms depend ; and it was called a cause of the disease, 
because diseases were defined by him to be an assemblage of symptoms. 
But this essential bodily change is a part of the disease rather than a 
cause, and is therefore better treated under the head of pathology. 
Discarding, then, the term proximate cause, we have now only to con- 
sider predisposing and exciting causes. 

14. The co-operation of both these kinds of causes is generally ne- 
cessary to produce disease. A number of persons are exposed to cold : 
one gets a sore throat; another, a pleurisy; another, a diarrhoea; an- 
other, some form of rheumatism ; and a fifth escapes without any disease 
at all. All five were exposed to the same cause, yet it acted differently 
on all. The first four were predisposed, each to the particular disease, 



38 



NATURE AND DIVISION OP CAUSES. 



which attacked them so soon as it was excited by the cold. The fifth had 
no predisposition, and the exciting cause was therefore powerless ; it 
was insufficient without the predisposing cause, as in the other cases, 
the predisposition was insufficient until the exciting cause, the cold, 
was applied. 

15. In some cases, however, what is in a smaller degree a predisposi- 
tion may, when it exists in a greater degree, constitute alone a sufficient 
cause of disease (§ 11:) thus a person with a very weak stomach always 
has indigestion, whether an exciting cause be applied or not. So like- 
wise exciting causes, if sufficiently strong, may produce disease without 
predisposition: thus a person not predisposed to indigestion maybe 
pretty sure to earn it, if he take a sufficient quantity of fat, raw cucum- 
ber, pickled salmon, or any such indigestible matter. Take another 
example. A healthy person living in a marshy district may not get an 
ague, until he becemes debilitated by any cause, such as cold, or fa- 
tigue : then the poison will act. But without his being thus weakened, if 
the exciting cause be made stronger by his sleeping on the very marshy 
ground itself, then the poison may act without predisposition, and the 
ague begins (§ 12.) 

16. The consideration of these facts throws some light on the nature 
of predisposition viewed as a cause. There is in organized beings a 
certain conservative power which opposes the operation of noxious 
agents, and labours to expel them when they are introduced into the 
body. The existence of this power has long been recognised, and in 
former days it was impersonated. It was the archceus of Van Helmont ; 
the anima of Stahl; the vis medicatrix naturce of Cullen. Now with- 
out supposing it to be aught added to the ordinary attributes of living 
matter, we may note its operation in the common performance of ex- 
cretion: we see it in the careful manner in which the noxious products 
of the body, and the useless constituents in food, are ejected from the 
system ; in the flow of tears which washes a grain of dust from the eye ; 
in the act of sneezing and coughing which remove irritating matters 
from the air passages ; and in the slower, more complicated, but not 
less apt example of inflammation, effusion of lymph, and those suppura- 
tive actions, by which a thorn, or any other extraneous object, is re- 
moved from the flesh. 

17. This vis conservatrix (§ 16) is alive to the exciting causes of dis- 
ease ; and in persons in full health it is generally competent to resist 
them. How it resists them depends on their nature. For instance : — 
Is cold the cause? If so the blood is thrown inwardly; and this, ex- 
citing the heart to quickened action, establishes a calorific process, 
which removes the cold. Is the cause improper food? The preserving 
power operates by discharging the offending matter speedily by vomit- 
ing or by stool. Is it a malarious or contagious poison ? It is carried 
off by an increase of some of the secretions. But if the resisting power 
(§ 16) be weakened, locally or generally, or if the exciting cause be too 
strong for it, then the cause acts, and disease begins (§ 15.) 

18. In the cases hitherto noticed, predisposing causes consist in ab- 
sence or deficiency of power (§ 16,) rather than in the existence of 
anything positive: but sometimes predisposition to disease depends on 
something positively wrong in function or structure, which yet alone 



PREDISPOSING CAUSES. 



39 



scarcely amounts to disease; and this fault may be congenital, or here- 
ditary, or acquired. 

19. It must be observed that predisposing causes operate chiefly 
through the general system or constitution ; hence they are often called 
constitutional or internal causes, in contradistinction to the exciting 
causes, which are more commonly external, or acting from without. 
But these terms are objectionable, because not always applicable. 
Sometimes the term predisposing is also inappropriate, as in the fol- 
lowing instance. Several persons are exposed to a malarious or in- 
fectious poison : some of these afterwards suffer from great fatigue or 
privation ; they then begin to show the effects of the poison : but the 
others who have not sustained this second influence, escape unhurt. 
The poison has entered the system in both cases ; but in the latter its 
influence is resisted ; while in the former the subsequent weakening so 
reduces the powers of resistance that the system yields before the ex- 
citing cause ; but occurring after, this weakening cannot be said to 
predispose. Hence, under such circumstances, the fatigue or privation 
is called the determining cause. 

Dr. Carpenter defines a cause to be a "force or power operating 
under certain definite material conditions," 1 in other words he consi- 
ders the antecedents necessary to produce a result as being of two 
kinds, dynamical and material. But these do not necessarily corre- 
spond with exciting and predisposing causes of disease, for a variation 
of force may constitute predisposition, and on the other hand altera- 
tions in material may become exciting causes. The fact is simply 
that the division of causes ordinarily adopted among pathologists is 
conventional and convenient rather than natural and philosophical. 
What are called causes are really circumstances that are essentially and 
invariably antecedent to disordered action. Some single circumstance 
may alone be discoverable ; or there may be two, three, or more, that 
have been acting simultaneously, or in succession. It is often conve- 
nient to specify some of these circumstances as predisposing the body to 
become diseased, others as determining the disease, and others as ex- 
citing or calling it up. But it is not always easy to say which ought to 
be termed a predisposition, which a determination, and which an ex- 
citement. The study of pathology and medicine is more difficult and 
uncertain than the study of ordinary physics, simply because the re- 
sults observed are nearly always consequent upon a combination of 
manifold causes, which are always varyiog in an infinite diversity of 
ways. Causes follow effects in the vital actions of the living body as 
certainly and as surely as they do in the working of the dead masses 
of Nature, but these causes are interwoven in a more complex way, and 
are subject to many more modifications. The results observed in pa- 
thology seem to be uncertain merely because the observer has an im- 
perfect knowledge of the antecedents and of their workings. When 
the properties of organized material, and the actions of living substance 
are as thoroughly understood as the properties of crude and unorgan- 
ized matter, the organic sciences will be found to be as precise as Phy- 
sics properly so called. 

1 "Principles of Human Physiology," 1853, p. 5. 



40 



PREDISPOSING CAUSES OF DISEASE 



SECTION II. 
PREDISPOSING CAUSES OF DISEASE. 

20. What for convenience sake we agree to call predisposing causes 
of disease are circumstances which so influence the functions or struc- 
tures of the body as to render that body unusually susceptible to the 
influence of particular exciting causes. Predisposing causes are, how- 
ever, in strict accuracy, different from predisposition. Predisposition 
is the state of the body which is brought about by the operation of these 
causes. Predisposing causes make the body unusually susceptible of 
certain diseases through predisposition in its structures or condition. 
Now the most important circumstances that operate in this way may 
be advantageously considered under the following heads. 

I. Debilitating Influence. 

II. Excitement. 

III. Previous Disease. 

IV. Present Disease. 

V. Hereditary Constitution. 

VI. Temperament. 

VII. Age. 

VIII. Sex. 

IX. Occupation. 

I. Debilitating Causes of Predisposition are the most numerous 
of all. This might be anticipated from the fact that constitutional 
strength generally implies power of resisting disease (§ § 16, 17.) The 
circumstances which are most influential in this way are such as enfee- 
ble the heart, impair the tone of the arteries, and reduce the activity 
of the secreting organs : often too an unusual susceptibility of the ner- 
vous system, which increases the liability of the body to suffer. The 
following are the chief agents of this class. 

21. (a.) Imperfect nourishment, either in consequence of defect in 
the quantity or quality of the food, or of incapacity of the digestive 
powers. This in itself causes many diseases, particularly of digestion 
and nutrition ; but it also weakens the power of the general system to 
resist cold, and produces a liability to low fevers, inflammations, and 
epidemic, contagious and endemic disorders. Thus the increased sus- 
ceptibility of the body to the influence of cold and infection, when fast- 
ing, is generally acknowledged; the rapid propagation of infectious 
diseases among an ill-fed population, like the poor Irish, is but too well 
known ; and to the disgrace of our nation it must be acknowledged that 
insufficient and unwholesome food has been one of the unhappy circum- 
stances that have contributed to render our brave troops in the Crimea 
an easy prey to disease and death in various forms. The same cause, 
too, especially lays the body open to the injurious influences that in- 
duce zymotic disorders. The offensive odour of the breath and excre- 
tions on the approach of death from starvation, proves that there is 



EXEMPLIFIED AND EXPLAINED. 



41 



depravation and incipient corruption in the materials of the body, as 
well as weakness. 

22. (b.) Impure air. The injurious effects of this are manifested in 
the pallid, cachectic complexion of the inhabitants of crowded cities, 
even of those who live well and regularly. How strikingly this con- 
trasts with the ruddy countenance of the hardy and coarsely-fed moun- 
taineer! So are the former also distinguished in the greater liability 
of these classes to diseases, particularly to those of the organs of re- 
spiration, circulation, and nutrition. No circumstance seems to ope- 
rate more extensively in favouring the spread and increasing the viru- 
lence of such pestilential diseases as the plague, typhus, malignant 
scarlatina, and the measles, than impurity of air. It effects this in 
two ways. In the first place it weakens the body, and so acts as a 
true predisposing cause. But in the second place it leads to the con- 
centration and increased virulence of the poison itself, which is diluted 
and destroyed by the influence of ventilation and fresh air. The im- 
perfect performance of the processes of respiration and cutaneous 
transpiration in small and close habitations makes persons offensive 
both to themselves and to others, in consequence of corrupt matter 
which ought to be eliminated being left in the system. This makes 
the soil fertile (so to speak) for the fostering of the seeds of disease, 
although it may alone be inadequate to the production of disorder. The 
evil influence of over-crowding human dwellings has been abundantly 
and forcibly illustrated during the prevalence of epidemic cholera in 
our own and foreign lands. 1 

23. (<?.) Excessive exertion of body or mind. Moderate exercise is 
beneficial to both body and mind; but when, either in degree or con- 
tinuance, this exceeds what the strength can bear or rest can recruit, the 
animal functions become exhausted, and lose their balance; muscular 
tone is impaired, nervous excitability takes the place of strength, the 
circulation fails, congestions ensue, the blood is not properly purified, 
and the various organs get to the brink of disease. It is hence that 
the fatigued mind or body is peculiarly prone to succumb before 
causes of disease. It has been observed in India that regiments were 
especially liable to be attacked by prevailing epidemic and endemic 
disorders when suffering from fatigue after forced marches. This has 
been sadly exemplified in the disastrous results of the siege of Sebas- 
topol, where excessive fatigue in addition to cold and privation de- 
stroyed thousands of the British army. Want of sleep has a similar 
effect ; and when the body is extremely exhausted, even sleep, which 
is nature's best restorer, is disturbed by the imperfect performance of 
circulation and respiration through excess of weakness: hence there is 
a liability to insomnia and nervous excitement in states of exhaustion. 

24. (d.) Want of exercise and sedentary habits generally also fa- 
vour the production of disease. The healthy vigour of the various 
functions of body and mind is best maintained by equal and moderate 
exercise ; and the torpor of inactivity renders them more obnoxious to 
the causes of disease. The muscular function, and the circulation of 

1 See Mr. Grainger's Report on the state of certain parts of the Metropolis, &c, 1851. 
Also "British and Foreign Medical Chirurgical Review," January 1, 1853. 



42 



PREDISPOSING- CAUSES OF DISEASE 



blood, are the first to suffer ; hence first sluggish movements, and ulti- 
mately weakness, of the heart and other muscles. The defective cir- 
culation too tells most in parts at a distance from the heart, producing 
cold extremities, dry skin, inactive liver, with its frequent concomi- 
tants, haemorrhoids, torpid bowels, and indigestion : whilst at the same 
time the heart itself, and the organs near to it, may be oppressed and 
injured by an undue load of blood, especially if the subject be pletho- 
ric; hence palpitation, dyspnoea, headache, vertigo, somnolency, dul- 
ness of the senses, &c, &c. In nervous subjects convulsive affections 
are often produced by this inequality of circulation. The respiration 
being little exercised, the task of decarbonizing the blood is imperfectly 
performed ; or devolves more on the liver ; hence the accumulation of 
fat in the textures, and the occurrence of bilious derangements. From 
this statement it will be obvious that sedentary habits, if excessive, 
may alone be equal to the production of disease, and that where they 
exist in less degree they may predispose to its production by other 
causes, such as irregularities of diet, exposure to cold, violent exertion, 
&c. From such combination of influences arise various disorders of 
the digestive organs, heart, lungs, and brain; catarrh, gout, rheuma- 
tism, calculous affections, diseases of the skin, &c. 

25. (e.) Long -continued heat. The debilitating effects of this agent 
are abundantly exemplified in warm climates and seasons. Under its 
influence, the muscles, and with them the heart and arteries, lose power 
and tone ; the textures become relaxed ; perspiration is profuse : and 
internal organs, especially the liver, are too much stimulated by blood 
which has lost more than its usual amount of water, and less of its 
hydro-carbon. Hence arises a disposition to bilious and liver complaints, 
dysentery and cholera. The function of respiration is much less active 
in an atmosphere at a high temperature, than when it is cooler. Less 
oxygen is then taken into the body, and the effete products of decay 
are less rapidly carried off by oxidation. The odour of the perspira- 
tion and other secretions thence becomes strongly offensive, and the 
blood is kept in a state prone for the reception and propagation of zy- 
motic morbific agencies. Overheated rooms and excessive clothing 
predispose to disease in the same way by their weakening and relaxing 
influence. It may be remarked that most of the diseases of hot climates 
and seasons occur rather at the termination of the greatest heat, than 
during its steady prevalence, and that therefore this predisposes to, 
rather than excites, the disease, which is really the immediate effect of 
cold, or of irregularity of diet, or of malaria. Thus the bilious diar- 
rhoea and cholera of this country occur chiefly in the early autumn, 
when the cool of the evening is strongly contrasted with the heat of 
the day. The chill suddenly arrests the perspiration, and throwing 
the blood inwardly, oppresses internal organs, especially the liver, 
whose resisting and reactionary energies have been exhausted by the 
influence of the previous heat: hence coldness of the surface and con- 
gestion of the liver and portal system, precede the more active symp- 
toms in flux, cholera, diarrhoea, dysentery, &c. 

26. (/.) Long -continued Cold. The experiments of Chossat and 
others clearly prove cold to be a direct sedative, capable of reducing 



EXEMPLIFIED AND EXPLAINED. 



43 



all the vital powers. Cold applied suddenly and for a short time, in- 
vigorates, because it then induces a healthy re-action, by which the 
vital properties are exercised and exalted. But when long continued, 
its own sedative and debilitating effects are permanent: it weakens the 
circulation, especially that of the surface, causes internal congestions, 
and directly depresses all the vital energies. The most malignant 
forms of epidemic fever in this country prevail towards the close of 
very severe winters ; and all diseases then frequently assume a typhoid 
type. This is observed chiefly among the lower orders, whose means 
do not enable them to protect themselves sufficiently against the in- 
clemencies of the season. We have before adverted to the striking 
manner in which cold disposes the body to suffer from malaria (§ 19.) 

27. (g.) Habitual intemperance in intoxicating liquors. There is 
probably, in this country, no source of disease more fertile than this. 
Besides many disorders which are directly excited by it, it predisposes 
to attacks of fever, erysipelas, dysentery, cholera, dropsy, and rheuma- 
tic and urinary diseases; and if it do not increase the proneness to in- 
flammatory disorders, the habit of intemperance certainly disposes such 
affections to unfavourable terminations, and causes many a victim to 
sink after accidents and operations, which would have been compara- 
tively trifling affairs in more sober subjects. Nor can we wonder at 
the pernicious effects of this kind of excess, when we consider the 
weakened state of function and structure which stimulating drinks in- 
duce, especially in the organs which they most directly affect, the sto- 
mach, the liver, the kidneys, the blood, the heart, and the brain. We 
shall soon have to explain how unsound states of these organs thus in- 
duced peculiarly impair the powers of the body to resist or throw off 
disease (§ 17.) 

28. (h.) Depressing passions of the mind, such as fear, grief, and 
despondency. Many are the instances in which bodies of men, as well 
as individuals, have escaped a prevalent disease, until depressed by 
some unhappy event or apprehension, and then have fallen victims to 
it. This was exemplified in the ill-fated Walcheren expedition, as well 
as in many incidents in the history of other armies in pestilential coun- 
tries. A defeat, a failure, or even bad news, have made hosts suc- 
cumb to the pestilence, who had before escaped. It is a common re- 
mark, that when a contagious or epidemic disease prevails, those who 
take most precautions frequently suffer most, because they are timid 
and fearful ; the stout-hearted and reckless escape unscathed. Persons 
whose mental and bodily functions are sustained by confidence and 

- courage, or are excited by enthusiasms, are much less prone than 
others to suffer from the depressing influence of fatigue, cold, wet, ma- 
laria, and infection. Anxiety and great mental exertion tend to waste 
the tissues of the body, and in doing so they not only weaken the frame, 
but load the blood with excrementitious matter, which may become a 
nidus for the propagation of zymotic poisons. 

29. (i.) Excessive and repeated evacuations, either of blood or of 
some secretion. The weakening effect of a large loss of blood needs 
no explanation ; but the injurious influence of habitual losses or drains, 
when these are more than the system can simultaneously repair, is 



44 



PREDISPOSING CAUSES OF DISEASE 



however even greater; for the vital functions then become depraved as 
well as depressed, a state of cachexia as well as anaemia is induced, and 
very trifling causes suffice to determine grave states of disease. Menor- 
rhagia, diarrhoea, leucorrhoea, and other hemorrhages and fluxes, if ex- 
cessive, reduce the powers of life and the capacity to resist disease. 
No loss of this nature, however, weakens so much or so irreparably, 
as excessive secretion of semen. In many of the lower tribes of ani- 
mals, the males live till they copulate, and then die : the reproduction 
of the species is at the expense of the individual. That our own species 
is not wholly exempt from this law of organized nature, is apparent 
from the fact that immoderate venery produces extreme debility and 
premature decay, and predisposes body and mind to various diseases. 

30. (/.) Previous debilitating diseases. It is well known that the 
body is unusually liable to contract fresh disorder during convalescence 
from serious maladies. It is then weak in all its powers ; and the ner- 
vous system often obtains the ascendency which is common in states of 
weakness, and which renders the body unusually susceptible to mis- 
chief (§ 23;) improper food, exertion, excitement, or exposure to cold, 
at such times readily produce the former or some new complaint. 
Hence convalescence from a severe disease is a state requiring pecu- 
liar care. The functions are just resuming their balance, and have 
neither the vigour of action nor the power of resistance which is the 
attribute of robust health. The diseases which leave the body most 
liable to this species of derangement are those ending in exhaustion ; 
as continued fevers and protracted and severe inflammations. 

31. II. Hitherto we have considered only those circumstances which 
predispose to disease through a weakening influence (§§ 16, 17, 20.) 
There are, however, other circumstances of a somewhat opposite cha- 
racter, which favour the production of disease through states of ex- 
citement OR activity. Full living, without an adequate amount of 
exercise, often brings the circulation and other functions up to a high 
pressure degree of activity without producing disease; there is then re- 
dundancy of health, and a more than usual capability of resisting those 
causes of disease which operate by depression, such as cold, malaria, 
and infection. But there is a predisposition to suffer from causes of 
additional excitement; thus irritants then more readily induce inflam- 
mation; violent exertion causes hemorrhages; and the stimulation of 
almost any organ may heighten the vital actions to a morbid pitch 
(§ 5 — 8.) So, also, unusual vascular activity in a part, although in- 
sufficient to produce positive disease, may render the part more liable 
to suffer upon the supervention of external causes. Thus the determi- 
nation of blood to the uterus and mammae at certain periods renders 
those organs then more liable to disease. Violent exertion makes the 
muscles, or their fasciae, peculiarly prone to rheumatic inflammation on 
the application of cold and damp. Excessive indulgence in stimulant 
diuretic beverages, (such as punch,) renders the kidneys liable to in- 
flammation or congestion on exposure to cold. Inflammation or irri- 
tation of the intestines is not a common effect of cold, but often be- 
comes so when these viscera are under the exciting influence of a pur- 



EXEMPLIFIED AND EXPLAINED. 



45 



gative. The brain, if previously over active from hard study, may be 
excited into inflammation by alcoholic stimulus, or strong moral emotion. 

32. III. Proclivity to disease is not unfrequently a consequence of 
previous disease, independently of the mere weakening influence al- 
ready noticed (§ 30.) This is particularly instanced in some inflam- 
matory and nervous disorders. Thus, a child who has once had croup 
is very liable to its recurrence. One attack of enteritis frequently 
predisposes to another. Convulsive disorders, such as chorea, hysteria, 
and epilepsy, are extremely apt to recur; and the longer they have ex- 
isted, the more difficult are they to remove, and the more ready are 
they to reappear on the application of any exciting cause. This, which 
may be called a habit of disease, it is most important to prevent. There 
can be little doubt that the previous attack, in all such cases, leaves 
some change of structure or function (§ 18,) which constitutes the pre- 
disposition, although it may be of a nature to elude our means of de- 
tection. 

33. Under this head may also be arranged many constitutional pre- 
dispositions to disease which are ascribable to the persistence in the 
system of a cause of some previous attack rather than to the attack 
itself. Rheumatism, gout, gravel, many cutaneous diseases, dropsy, 
and jaundice, may be quoted as examples. A person who has once 
suffered from any of these is very liable to a recurrence on the appli- 
cation of an exciting cause ; and this is because, although free from 
the first attack, he may not have lost some functional or structural im- 
perfection (§ 18) which was the predisponent to that attack, and which 
may therefore again produce a like result upon the addition of an ex- 
citing cause. In most of these cases the constitutional defect is in 
some of the processes of assimilation or excretion, and generally of a 
functional nature, but occasionally it is also attended with change of 
structure, especially in the great eliminating organs, the liver, the in- 
testines, and the kidneys. 

Nor can we separate from this class of constitutional causes certain 
(§ 32) predispositions to structural disease, of a tuberculous and ma- 
lignant nature. Where products of this kind have once appeared, there 
is a tendency to the production of more, although such tendency may 
be latent until brought into activity by an exciting cause. In the fol- 
lowing pages many arguments will be found which favour the view that 
the disposition to such disorders is connected with faulty functions of 
assimilation and excretion. 

34. IV. Disease already existing in the body, even when itself 
latent, often predisposes to other disorders, independently of its mere 
weakening effect. (§ 20.) Thus tubercles and other tumours, struc- 
tural lesions of the heart and other organs, often induce irritations or 
obstructions of blood-vessels, which, if not the cause of immediate and 
manifest disease, nevertheless lead the way to the production of disor- 
der by other causes. A person on the occasion of violent bodily exertion 
(vocal or otherwise) is seized with profuse spitting of blood, which 
causes his death: on opening the body many tubercles are found in the 



46 



PREDISPOSING CAUSES OF DISEASE. 



lungs, although there had been no obvious symptoms of their existence 
before the violent effort. Or, again, disease of the heart causing ac- 
cumulation in the veins, often leads to congestion of the lungs and 
liver ; and it may only require the addition of an exciting cause, such 
as sudden exertion or an excess in diet, to bring about an attack of 
asthma or jaundice. These are instances of causes coming into opera- 
tion by accumulation. Granular disease of the kidneys, which impairs 
the excreting power of these organs, renders the body more liable to 
suffer disease through the operation of infectious and other poisons, as 
well as of other exciting causes. Febrile and inflammatory diseases 
often leave in the body more or less of effete material, which is prone 
to decomposition, and which sets up derangement in the blood, skin, 
mucous membranes, and other structures, on the application of any 
trivial exciting cause, thus causing eruptions, fluxes, and analogous 
mischief. — The dregs of one malady, in this way, prepare the body for 
the occurrence of a second. 

Dr. Carpenter 1 has recently pointed out a probable modus operandi 
of the predisposing causes of Zymotic disease, (see Section IV.) which 
connects itself with the matters under consideration. Such disorders as 
puerperal fever, erysipelas, yellow fever, eruptive fevers, cholera, and 
dysentery are observed to be most readily propagated, as well as to 
assume more grave characters, in proportion as an albuminous material 
prone to decay, abounds in the body, whether it be introduced from 
without, or result from the disintegrating processes of the system; in 
either case being retained in consequence of the imperfect action of 
the excretory or eliminating apparatus. — Such decomposing principle 
(then in fact equivalent to a diseased condition of the fluids) becomes 
a predisposing cause of disorder, and renders the body obnoxious to 
infection from the influence of the slightest amount of morbid poison. 
This is well seen in puerperal females : when the uterus is undergoing 
a process of rapid disintegration in such, it is especially prone to con- 
tract the state that leads to the disorder known as puerperal fever, 
from any medical attendant who has been in close connexion with the 
disease either in the living or dead subject. Those who are suffering 
from accidents or surgical operations are in the same way liable to 
catch erysipelas and a peculiar form of adynamic fever, which are, ac- 
cording to Professor Simpson, capable of being carried from patient to 
patient by the hands of the surgeon, and which are then capable of 
producing the same morbid states in other subjects. 

The debilitating influences already noticed, imperfect nourishment 
(§ 21,) impure air (§ 22,) excessive exertion (§ 23,) and habitual in- 
temperance (§ 26,) predispose to Zymotic diseases, not only by their 
general depressing agency, but also by impairing the condition of the 
blood, and by increasing in it the quantity of an azotized matter in an 
incipient stage of corruption, and serving as an appropriate nidus for 
the propagation of a morbific poison. In all cases of this kind, the 
predisposition must be referred to a morbid state already present in 
the system. 



1 "British and Foreign Medico- Chirurgical Review," January, 1853. 



TEMPERAMENT — AGE. 



47 



35. The predisposing causes hitherto considered may be called acci- 
dental or acquired. There are, however, other influences which are 
present in the individual at birth ; and yet others which arise from cir- 
cumstances of age or growth. All these may be referred to something 
defective or ill-balanced in the organization (§ 18,) but which is in- 
sufficient to manifest itself actively until wrought upon by an external 
exciting cause. 

36. Y. Of the predispositions present in the individual at birth, the 
most generally recognised is hereditary tendency to disease. It 
is well known that scrofula, gout, rheumatism, epilepsy, mania, asthma, 
blindness, and deafness, run in families. That this depends on indi- 
vidual peculiarities transmitted from parents to offspring, appears from 
the fact that all children do not partake alike of the disposition. Nay, 
sometimes a generation is free from a disease, which was present in the 
ancestor and appears again in the offspring. So too we see external 
organization, family likeness, differently stamped on different children 
of the same family. 

It must not be supposed that hereditary proclivity to disease com- 
mences at birth. In a few instances it is congenital ; but in a greater 
number it is developed by growth or some other circumstances in life. 
Gout, for example, is acknowledged to be hereditary ; a parent has it 
in middle or advanced life: the son does not get it until about the same 
period, a little sooner or later, according to whether he lives freely or 
not. Here is something which is transmitted from father to son, and 
yet not manifest in the son for forty or fifty years. 

37. VI. Frequently, but not necessarily, connected with hereditary 
conformation, is the peculiarity of constitution called temperament, 
which certainly predisposes to particular diseases. Temperament con- 
sists in a predominance or defect of some function or set of functions, 
viewed in relation to others (§ 9.) 

38. Thus the sanguine temperament implies an activity of the sys- 
tem which circulates florid blood, and a full proportion of red corpus- 
cles; it is manifested by an excitable pulse, flushing cheek, quick move- 
ments, and lively disposition. This temperament gives a predisposition 
to inflammation, determination of blood, and active hemorrhage (30.) 

39. The phlegmatic or lymphatic temperament is the reverse of the 
sanguine : it occurs in those who have a weak pulse, languid circulation, 
cold extremities, and pallid skin, — there is a deficiency of florid blood, 
and 'of vascular action and tone (§ 9,) and the proclivity is to watery 
fluxes, dropsy, and other chronic affections. 

40. The bilious or melancholic temperament, is commonly met with 
in persons of dark complexion and gloomy disposition ; there is proba- 
bly here defective action in some of the biliary or digestive organs, 
which are therefore the more liable to derangement (§ 9.) 

41. The nervous temperament is externally manifested only by agi- 
tation or trepidation of manner; it seems to depend on an excess, or 
want of right proportion, of some of the properties of the nervous sys- 
tem (§ 9,) and predisposes to the disorders called nervous, such as hys- 



48 



PREDISPOSING CAUSES OF DISEASE. 



teria, nervous pains, and spasms. These temperaments may be va- 
riously combined. 

The word diathesis is often used to express a particular morbid 
tendency; thus we hear of the inflammatory diathesis, the scrofulous 
diathesis, &c. It is merely another word for disposition, and affords 
no clue to the nature of the thing spoken of. 

42. VII. The last group of predisposing causes to be noticed re- 
lates to age. The several changes in organization, as well as in ex- 
ternal circumstance, which the animal frame undergoes at different 
periods of life, may naturally be expected to be attended with corre- 
sponding variations in the proclivities to disease. I proceed to enu- 
merate a few of these, premising that some of the examples may be 
entitled to rank with exciting causes of disease, as well as with pre- 
dispositions. 

43. (a) In early infancy, the low calorific power of the body dis- 
poses it to suffer readily from the bad effects of cold (§ 17,) whence the 
tendency at that time to visceral inflammations. The skin is particu- 
larly liable to various eruptions in consequence of its tenderness and 
its not being habituated to the new and drying medium in which it is 
placed. The redness of new-born children is obviously the result of 
the irritating action of the air; it often assumes the form of a vivid 
erythema, and is followed by desquamation of the cuticle, and a yellow 
stain of the skin beneath, from extravasated hsematosin, which is some- 
times erroneously thought to be a kind of jaundice. Strophulus and 
other papular eruptions often succeed. The comparatively unused 
state of the alimentary canal at birth renders it also peculiarly suscep- 
tible of disorder; another trial awaits it at the period of weaning — 
hence arise diarrhoea, vomiting, colic, waterbrash, atrophy, and other 
ailments connected with disordered digestion. The brain, excited by 
the novelties of the external world, becomes rapidly developed, and, in 
its increased activity and growth, is rendered liable to various diseases, 
(§ 30 ;) hence the proclivity to hydrocephalus, convulsions, &c. The 
process of teething adds an irritation, which acts on the nervous system, 
the bowels, and the air passages, and disposes them to get readily dis- 
ordered. 

44. (5) In childhood, or the age from infancy to puberty, the func- 
tions most active are such as administer to growth: the organs of 
digestion and assimilation are therefore obnoxious to disorder (§ 32 ;) 
hence the frequency of derangements of the stomach and bowels, worms, 
infantile remittent, &c. The activity of the nutritive function gives a 
preponderance to the protein constituents of the blood ; and inflamma- 
tions which incidentally occur are commonly attended with the effusion 
of much plastic or albuminous matter; as seen in the products of croup, 
and mesenteric disease, tubercle, &c. The natural mobility (or activity 
of the excitomotory system) of childhood predisposes to chorea and 
kindred affections (§ 30.) 

45. (c) Puberty brings with it many morbid susceptibilities, but 
especially in the female sex, in which the important function of men- 
struation is then established. Many and serious are the evils which 



ADVANCING AGE. 



49 



are liable to be produced by external causes, that tend to check the 
development of this function. This function when established has its 
nervous as well as its vascular relations ; and hence, where it is irregular 
or disordered, a predisposition is given to many maladies affecting the 
blood-vessels and their contents, the secreting organs, and the nervous 
system. 

46. (d) At the termination of growth, there is another critical period. 
The cessation of the appropriation of nourishment to the increase of 
the body, may, in the more robust, cause fulness of the vessels, and a 
disposition to hypertrophy, hemorrhage, and inflammation ; and in the 
cachectic, it may lead to morbid depositions, especially of the tubercu- 
lous kind (§ 47.) The same redundancy of the vivifying fluid in active 
circulation, gives that buoyancy of animal spirits and impulsive energy 
of feeling and strength, which are the characteristics of healthy youth ; 
yet this very exuberance of vital power, if not properly controlled and 
balanced, constitutes a tendency to disease ; either directly, as where 
excitement, rising beyond the limits of health, borders on morbid ac- 
tion (§ 31;) or indirectly, as where excessive exertion leads to subse- 
quent exhaustion (§ 23.) Youth is the age of susceptibility to moral 
and physical impressions ; and therefore of liability to the disorders 
which these are capable of producing. 

47. (e) Adult age can hardly be said to predispose to any diseases, 
unless it be such as arise out of the mode of life then pursued. It is 
commonly a period of comparatively steady health, because the func- 
tions are then very evenly balanced; but if the mode of life be un- 
favourable, bad habits are apt to become established, and by their con- 
tinuance to induce disease. Thus gout, gravel, rheumatism, indigestion, 
and various other disorders, are apt to occur in middle life, because the 
predisposition to them is then gradually engendered (§ 24) by some 
error in diet or regimen, too slight to excite disease at once, but suffi- 
cient by accumulation to dispose to it, and so to allow of its being 
manifested on the application of some exciting cause. 

As age advances, such habits as overstrain and exhaust the strength 
of the organs, begin permanently to affect the organization, accelerating 
those changes by which human existence is limited to a span of years. 
This occurs sooner in proportion as the powers of the system have been 
expended by hard and irregular living, bodily hardships or mental 
anxiety, and later accordingly as prudence and moderation have been 
the guides: different people manifest marks of senility, and senile dis- 
position to disease at very various periods of their lives. It would occupy 
too much space to enter into a detailed account of these changes, but 
some of the principal of them may be briefly noticed, as illustrating 
the peculiar weaknesses and liabilities of advanced age. 

48. (f) The changes which old age induces in the exterior of the 
body are connected with a failure of those functions which are most 
active in youth. Instead of muscles, fat, and integuments being 
nourished in the several proportions that give beauty as well as strength 
to the form in mature life, the muscles get thin and sinewy; fat be- 
comes scanty, partial, or in excess; the integuments are loose and 
wrinkled, or fat and flabby; the joints stiffen, and the gait loses its 

4 



50 



PREDISPOSING CAUSES OF DISEASE. 



firmness and uprightness. These changes in the textures of the body 
are attended, and probably induced, by altered relations in the different 
parts of the vascular system. The pallid skin of age, contrasted with 
the ruddy blush of youth, indicates the diminished development of the 
capillary blood-vessels, that great system, which sustains the life and 
nutrition of the body ; much of the blood that in earlier age circulated 
on the surface, giving vigour and sensibility to all the external organs, 
and life and susceptibility to all outward relations, becomes accumulated 
in the interior, and confines its vivifying and nutrient influence chiefly 
to the internal functions and structures, thus tending to render the in- 
dividual more isolated and selfish. But the blood that is kept back in 
the larger vessels, is not equally distributed within them. The di- 
minished capillaries intercept some of the force by which the nutritive 
fluid is propelled through the arteries: hence it stagnates and accumu- 
lates in the veins, which become distended and tortuous; but the ar- 
teries, being at the same time exposed to the continued impulsive force 
from the heart, lose much of their elasticity, and become rigid tubes, 
thus causing the peculiar hardness of the senile pulse. The nutrition 
of the textures generally fails, not in degree only, but in kind also, 
and chemical transformations and deposits begin to show themselves 
in the different structures. The fibrous and muscular tissues exhibit 
partial conversion into fatty matter, and osseous or petrifactive changes 
encroach on many structures of low organization ; there is a tendency 
to degradation towards the composition of mere vegetable and mineral 
matter. 

This altered condition of the blood-vessels brings with it morbid ten- 
dencies, the nature of which will depend much on the state of the great 
moving power, the heart; now more than ever the prime agent in the 
circulation. If the heart be moderately strong, a fair balance may long 
be sustained ; although hemorrhoids, varicose veins, and such results 
of local obstructions, may occur. If the heart be too strong, (which is 
often the case after a life of much muscular exertion,) the small ar- 
teries frequently suffer from the unsoftened force of its pulses, par- 
ticularly in the brain, and there is a liability to apoplexy or palsy: the 
same thing in mucous membranes forms a disposition to active fluxes, 
catarrh, asthma, and affections of the urinary organs. The more vas- 
cular textures, especially of internal organs, are over nourished, and 
increase in size or weight. If the heart be weak or diseased, there 
will be imperfect circulation and tendency to venous congestions, drop- 
sical effusions, imperfect and disordered secretions, altered nutrition, 
and a general failure of all the functions which depend on a sufficient 
supply of arterial blood : diseases of the liver, stomach, kidneys, lungs, 
and other viscera arise in this way: in extreme cases the lower extre- 
mities actually die for want of circulation. 

If instead of the organs of circulation we w r ere to take the alimen- 
tary, the respiratory, or the urinary apparatus, we should also here 
find changes induced by age, which show that man's organization is 
only intended to last a limited time. Old age is thus attended with 
increasing infirmities and liabilities to disease (§ 16, 18.) The very 
strength and activity which some functions retain, may, in consequence 



OLD AGE — SEX. 



51 



of their partiality, endanger life; but their gradual and more equal 
failure degrades the physical, and often the mental, frame of man to 
a lower scale of existence, until he sinks into second childhood, dotage, 
and decrepitude. 

49. VIII. Sex. The liability which sex gives to the diseases of 
the respective generative organs is too obvious to need mention. But 
the peculiarities of sex are not confined to the generative organs : they 
extend to many other of the structures and functions of the body. 

The male sex is peculiar in the higher development of the muscular 
and voluntary excitomotory system, and a corresponding strength of 
frame; — in the stronger impulses of the animal passions; and in the 
greater endowment of the reasoning faculty. These respectively bring 
with them a liability to suffer from diseases of the muscles, limbs, joints, 
heart, and great vessels ; — from the evils contingent on undue indul- 
gence of passion or appetite; and from disorders of the brain and its 
intellectual functions. 

In the female sex the predominant bodily functions are the nutritive, 
the sensitive, and the involuntary excitomotory; and the perceptive 
and instinctive faculties, and moral emotions, preponderate in the mind. 
Hence the greater proneness of females to changes in flesh and blood; 
to disordered sensation, spasm, convulsive and other affections of the 
spinal system ; and to the direct and indirect consequences of indul- 
gence or thwarting of instinctive moral feelings. The predisposing 
influences of the menstrual function have been before noticed (§ 45 ;) 
it may now however be added, that its cessation favours the develop- 
ment of various diseases of function and structure, especially growths, 
simple and malignant. 

50. IX. Occupation comprises many circumstances already no- 
ticed under the heads of predisposing influences. Thus, sedentary 
occupations imply want of exercise (§ 24,) and sometimes impure air 
(§ 22 ;) laborious employments operate like excessive exertion (§ 23 ;) 
other occupations predispose to disease by the continued exposure to 
heat (§ 25) or cold (§ 26.) Some employments require constrained 
postures, which if insufficient to induce, may yet promote the occurrence 
of disease ; thus engravers and watchmakers are liable to affections of 
the head, because they hold it low; shoemakers and tailors are subject 
to disorders of the stomach, because they compress it during their 
work. In many other instances particular occupations induce disease 
rather by exposing the individuals to the exciting causes, than by in- 
ducing a predisposition ; but as before remarked, the very circumstances, 
which, when in great intensity suffice to excite disease, when acting in 
a lower degree may only induce a disposition to derangement. Thus 
the slow introduction of lead into the system, so commonly occurring 
in the occupations of painting, plumbing, card-enamelling, and printing, 
may not cause colic until cold or irregularity of diet becomes an addi- 
tional or exciting cause. The same remark applies to dry grinding, 
needle-pointing, leather-dressing, and other unhealthy occupations. 
The time during which such employments are pursued is an important 
element in the result ; thus an occupation, not in itself unhealthy, may 



52 



EXCITING CAUSES OF DISEASE, 



become so when continued too many hours in the day; and a work 
which is attended with risk may be often safely undertaken for short 
periods, a due amount of relaxation or diversion to another pursuit 
being allowed between. By attention to this point, the injurious in- 
fluences of occupations may be much lessened. 



SECTION III. 



EXCITING CAUSES OF DISEASE. 



51. We now pass to the consideration of exciting causes of disease ; 
that is of such circumstances and agents as seem to be operative in 
producing disease in the body, more especially when in a state of pre- 
disposition (14.) It has been stated before (§ 11, 15,) that certain 
powerful agents, of the nature of irritants or poisons, pretty surely 
cause disease, independently of peculiarity of constitution or predispo- 
sition ; but peculiar constitution or predisposition may even then modi- 
fy the character of the disease in different cases: where the exciting 
agents are less powerful, as in the case of most common causes of dis- 
ease, the effect depends still more on the influence of predisposition, 
and may be altogether inappreciable when this is not strong (§ 15, 19.) 

Exciting causes of disease, then, are certain external circumstances 
which have been observed to be very frequently present when certain 
diseases occur. Because the diseases seldom appear unless these cir- 
cumstances have been present, they have come to be considered as es- 
sential to the result, and in the light of excitements to it. Hence they 
are designated exciting causes. jS~ow such influences may be con- 
veniently distributed into two divisions, as cognizable and noncog- 
NIZABLE agents. The former class comprehends physical and mental 
influences, of whose existence we can take cognizance, independently 
of their operation in producing disease; thus cold we know by its ef- 
fect on our instruments and organs of sensation ; muscular exertion, by 
our witnessing or making it ; and mental emotion, by our conscious- 
ness of it. The noncognizable causes, on the other hand, elude our 
senses, and we infer their existence only from their morbific effects : 
thus malaria and infection are only observed in their morbific results. 
The subjoined table specifies the different kinds of influences that are 
comprised within these several divisions. 



f 



Exciting Causes 
of 

Disease. 



I. Cognizable 
Agents. 



II. Noncognizable 
Agents. 



L & 



Mechanical influences. 
Chemical influences. 
Ingesta. 

Bodily exertion. 
Mental emotion. 
Excessive evacuation. 
Suppressed or defective evacuation. 
Defective cleanliness, ventilation, and 
drainage. 

Excesses and changes of temperature. 

f 1. Endemic "] 
■J 2. Epidemic I Poisons. 
( 3. Infectious J 



MECHANICAL AND CHEMICAL. 



53 



I. COGNIZABLE AGENTS. 

52. (1.) Mechanical causes, which injure structure; or impede, 
or derange function. Besides the obvious instances afforded in tear- 
ing, cutting, pinching, striking, and straining, which produce at once 
diseases that fall within the province of the surgeon, there are also 
many mechanical sources of mischief that come under the physician's 
notice. Long-continued pressure of articles of clothing sometimes 
produces disease. Tight neckcloths may cause headache or even apo- 
plexy, by impeding the flow of blood from the head. Tight stays may 
produce fainting, by pressure on the heart and great vessels, and colic 
and costiveness and other disorders by obstructing the free passage 
through the great intestines. Pressure on the epigastrium after a 
meal, caused by sitting at a desk, may excite indigestion. Long con- 
tinuance in one position, whether standing, sitting, or lying, tends to 
obstruct circulation and innervation, and to produce swelling and 
paralysis of the parts of the body that are beyond the seat of pressure, 
and this in time may even cause inflammation and death of the parts 
pressed upon. But mechanical causes may also be operative within 
the body. A stone in the bladder irritates by its mechanical proper- 
ties, especially if it be of an angular shape ; or it may mechanically stop 
the flow of urine: so also may a gall stone stop that of the bile. The 
intestinal canal is sometimes mechanically obstructed by hardened 
feces, until irritation and inflammation ensue. The stomach is often 
mechanically irritated by the bulk, hardness, or asperities of its con- 
tents: and vomiting, indigestion, or inflammation of the organ, may 
be thereby induced. The air passages of needle-pointers, stone-masons, 
&c, are irritated and inflamed, and at length become altered in 
structure, in consequence of the mechanical action of particles of stone 
or other substances, which these men inhale in the course of their em- 
ployment. 

Instances of this kind are endless : certain of the structural effects 
of disease also exercise considerable mechanical influence. Tumours, 
diseases of the heart and vessels, the lungs and air passages, intestines, 
and urinary apparatus, and injuries and diseases of the bones and liga- 
ments, afford abundant illustrations of this mechanical causation of 
disease. 

Some mechanical injuries, when extensive, besides their simple ef- 
fects on structures and functions, directly depress the vital powers ; 
thus, concussion of the brain, crushing or tearing off a limb, or a blow 
on the t epigastrium, induces fainting and extreme weakness of the 
heart's action, and may thus even cause death. Slighter mechanical 
injuries are causes of irritation or excitement, which may be local or 
general, according to the excitability and extent of the part irritated. 

53. (2.) Chemical causes of disease are even more varied than me- 
chanical, because the several chemical agents are more numerous than 
the mechanical. We are acquainted with the chemistry of the animal 
body less than with its mechanism, and therefore can the less clearly 
distinguish causes which act by chemical properties, from those which 
have complex relations to vital properties, than we can those which are 



54 



EXCITING CAUSES OF DISEASE. 



mechanical. But we recognise chemical irritants in acids, alkalies, 
and many salts, whether applied to a part, or inhaled in form of gas 
or vapour. So what are called chemical poisons, such as corrosive sub- 
limate and other metallic salts, the strong acids and alkalies, iodine, 
chlorine, &c, produce disease by their known powerful chemical affini- 
ties, which tend to decompose tissues and disordered functions. 

"We cannot doubt that many of the matters which cause disease in 
the alimentary canal, do so by virtue of their chemical qualities. The 
process of digestion, although always in part chemical, is so under the 
superintendent influence of a superior vital power : no sooner does this 
power fail, or the chemical agencies or decompositions become too 
strong for it, than we have fermentation and putrefaction, which cause 
eructation of gas or sour liquid from the mouth, and there may follow 
the discharge of ill-coloured and unusually fetid matters by stool ; then, 
too, may arise a number of disorders, which may in great part be re- 
ferred to the influence of these injurious chemical processes. 

There appear to be at least four modes in which chemical agents 
may excite disease in the body: — 

1. By acting as local irritants, as do the diluted acids, alkalies, and 
various salts, the chemical operation of which is resisted by increased 
action excited in the part (§ 16.) 

2. By acting as corrosives, as in the case of strong acids, alkalies, 
some metallic salts, chlorine, and iodine, which by their powerful che- 
mical affinity, so completely overcome the vital affinities of textures as 
to decompose them and thus to kill and alter the condition of the part. 

3. By acting as sejjtics, promoting the decomposition of the fluids 
or solids of the body, in the same way that ferments or putrescent mat- 
ters operate on dead organic matter. 

4. By acting as chemical alteratives, modifying the changes which 
take place in digestion, assimilation, transformation of textures, secre- 
tions, &c, as instanced in the counteraction of acidity by alkalies, in 
variously influencing the state of the blood and urine by acids, alka- 
lies, &c. ; and in causing the production of hippuric acid in that excre- 
tion, by the administration of benzoic acid, and the increase of the 
solid constituents of the urine by the administration of salt, in the in- 
crease of the sulphates by the exhibition of liquor potassse, (Parkes ;) kc. 

The operation of chemical agents on the general system will vary 
according to the intensity of their action, and the extent of their ap- 
plication. Irritants, if extensively applied, cause feverish excitement. 
Corrosives, if acting widely, depress the vital powers, like the shock 
of violent mechanical injuries (§ 52;) if more partially, the vital powers 
are excited to resist them, thus corrosives operate as irritants. Septics, 
if very powerful, may speedily overwhelm the preserving vital powers 
of the body, which then speedily passes into a state of corruption, as 
in the case of extensive gangrene, pestilential diseases, &c. : but if the 
septic matter be scanty, and the vital powers strong, they are excited 
to increased action, and the body may by means of accelerated circu- 
lation, and augmented excretions, get rid of the offensive matter (§ 17.) 
Such kind of struggle is instanced in typhoid fevers, epidemic cholera, 
and dysentery, and other toxic diseases, which have received the ap- 



INGESTA — NON-ALIMEXTARY. 



55 



pellation of zymotic, from the supposed resemblance of their cause to a 
ferment. 

54. (3.) The solid and liquid ingesta are a fertile source of dis- 
ease, and this in various ways. Their mechanical and chemical pro- 
perties have already been noticed, (§ 52, 53.) But, they may also 
cause disease — 

a. As non-alimentary matters acting injuriously. 

b. As aliment faulty, or ill-proportioned, in quality. 

c. As aliment defective, or excessive, in quantity. 

55. (a) Of the non- alimentary matters contained in the ingesta, that 
are capable of exciting disease, salt, spices, pickles, and other condi- 
ments, and spirituous or fermented liquors, are illustrations. They 
are all more or less irritating or stimulating to the digestive apparatus ; 
and if used indiscreetly may induce inflammations, congestions, and 
functional disorders of these organs, and, in some instances, irritation 
of other parts, and of the whole system. Salt in moderation is bene- 
ficial as an adjunct to food, both on account of its antiseptic and sol- 
vent properties, and as supplying a part of the acid for digestion, and 
an alkali which is required in bile and other fluids: but if in excess, 
it irritates the stomach, retards digestion, and causes feverishness with 
thirst. Much of these effects is due to the affinity of the salt for the 
water of the animal fluids, and may be induced by other saline matters 
beside common salt. Wherever excess of salt is contained in the body, 
there will be osmosis 1 and exosmosis of the liquid amidst the adjoining 
vessels and tissues until the salt is equally distributed among them, and 
before this is accomplished, there will be such a diminution of the fluids 
within the blood corpuscles, and on the surface of membranes, as will rea- 
dily account for the thirst and disturbance caused in the system. Ac- 
cording to Liebig, salt impedes the deposition of fat. Animals will not 
fatten on salt food ; — this is a hint for the corpulent. Salt increases the 
elimination of urine by the kidneys; it has therefore been supposed to 
hasten the destructive metamorphosis of tissues. The absence of salt 
in food, especially if this be vegetable, favours the production of worms 
in the intestines. 

56. Alcoholic liquors act as stimulants when taken into the sto- 
mach. At first they provoke appetite and enable the organ to dispose 
of a greater quantity of food; but soon the digestive power fails in 
consequence of the exhaustion that necessarily follows undue excitement, 
and inappetency, nausea, or even vomiting ensues. The operation of 
these agents is, however, soon extended, for they are absorbed into the 
blood, -and their stimulant action is exercised on distant parts, espe- 
cially on the vascular and nervous system. As the absorption is ef- 
fected by the veins, they pass by the portal vein directly to the liver, 
and hence the function and structure of this organ are particularly 
apt to suffer from indulgence in spirituous beverages. So too as the 
kidneys are the natural emunctories through which extraneous matters 
are eliminated from the system, they get first over-stimulated, and 
then exhausted, and are injured in their secreting power, and ultimate- 



1 Professor Graham; "Proceedings of Royal Society," 1854. 



56 



EXCITING CAUSES OF DISEASE. 



ly in their structure also, if repeatedly exposed to the same injurious 
influence. The heart and vessels also are over-excited at first, and 
afterwards lose their tone : the processes of assimilation and nutrition 
are impaired and modified, and all the solids and fluids of the body 
become in some degree depraved. The nervous system suffers espe- 
cially from the disordering influence of intoxicating liquors. If a 
large quantity is taken at one time, it acts as a narcotic poison, in- 
ducing a short period of cerebral excitement or intoxication, and then 
insensibility, in which the functions of the brain are more or less com- 
pletely impaired, and in extreme cases those of the spinal marrow also; 
if the influence be insufficient to stop respiration, yet it may so far 
interfere with it as to lead to congestions in the brain and other or- 
gans. Hence apoplexy, palsy, phrenitis, or delirium tremens, may 
follow, and the whole frame may suffer from the effects of the poison. 
Even when less excessive quantities are taken, the headache, sickness, 
inappetency, and feelings of wretchedness and depression which com- 
monly ensue, sufficiently prove that grave disorder has been produced, 
and that such artificial excitements cannot be abused with impunity. 

Habitual indulgence in strong drinks causes other kinds of disease, 
which are so often seen that they deserve especial notice. When taken 
only, or chiefly, with food, not as a substitute for it, but as a consti- 
tuent of general a free living," fermented liquors contribute to the 
production of an abundance of ill-assimilated, overheated blood i 1 which 
either finds a vent in eruptions on the surface, or in local hemorrhages 
or fluxes, or causes various functional disorders, such as palpitation, 
vertigo, stupor, dyspepsia, and bilious attacks, or sometimes produces 
gout or gravel. The latter results more commonly follow when the 
beverages contain much free acid, as w T ell as an abundance of spirit, 
as is the case with port wine, rum punch, and hard strong beer. The 
less acid malt liquors, ale and porter, tend rather to induce liver dis- 
orders, and an abundant deposition of fat in the body. All these con- 
sequences are promoted by sedentary habits (§ 24) and deficient ex- 
cretion: for active exercise carries off much of the spirit and superfluous 
aliment, by an increased elimination through the aids of respiration and 
perspiration. 

The most disastrous consequences of intemperance are exhibited in 
the habitual drunkard, who in proportion as he indulges in liquor, 
loses his appetite for food, and his power of digesting it. He then 
drinks and starves at the same time; and the disease which ensues 
comprises the exhaustion of inanition together with the more direct 
effects of the alcoholic poison. Thus in delirium tremens, the drunk- 
ard's disease, besides the permanent restless excitement of the irri- 
tated nervous system, which adds more and more to the exhaustion, 
there is fearful weakness of mind and body ; and in bad cases even the 
organic functions are affected, so that the pulse is very weak and fre- 
quent, the excretions are scanty and depraved, and the respiration is 

1 This effect of alcoholic drinks, familiar to all observers, receives additional illustra- 
tions from the experiments of Dr. Bocker, which shows that they tend to diminish the 
urinary excretion, and the elimination of carbonic acid by the lungs. — British and Foreign 
Medico- Chirurgical Review, October, 1854, p. 398. 



NON- ALIMENTARY — FERMENTED LIQUORS. 



5T 



so imperfectly performed by the involuntary powers that sleep cannot 
ensue. This exhaustion soon terminates in death, unless the result is 
prevented by appropriate treatment; and this must comprise, besides 
opium (the common remedy,) ammonia and other stimulants to the 
circulation and respiration, purgatives and diuretics to free the blood 
from the excrementitious matter that has accumulated in it ; and fluid 
nourishment to repair its waste. Without these adjuncts, opium will 
not only fail to procure sleep, but if given in large doses may even 
paralyze the remaining powers of life. 1 

Pernicious as fermented liquors are in their abuse, yet these and 
other adjuncts to food when taken with careful moderation and dis- 
crimination, often prove beneficial by aiding the digestion where it is 
weak, and by counteracting various exhausting and depressing influ- 
ences, which frequently arise out of the artificial condition and em- 
ployments of society, especially. in large towns and in cold climates. 
It appears from the observations of Dr. Bocker, that alcoholic liquors 
used in moderation, prove beneficial in restraining the waste of tissues, 
and therefore in sustaining the nutrition of the body. In this respect 
its action is contrasted with that of water and of salt, and resembles 
that of tea and coffee. (Brit, and For. Med. Chir. Rev. Oct. 1854.) 
Total abstinence, therefore, is preferable to moderation, in many cases, 
rather because it is morally easier to practise, than because it is more 
salutary in its physical effects. 

Tea and coffee also, although refreshing and really invigorating ad- 
juncts to food when used in moderation, may excite disease when taken 
in excess: the derangements being chiefly those of the stomach and 
nervous system. Gastralgia, nervous palpitation, or fainting, insomnia, 
and even mental delusions, have been induced by the too free use of 
strong tea or coffee. Even water, the simplest, and it might be thought 
the most harmless of beverages, is not without its positive influence on 
the animal economy, and if taken in excess, is capable of producing 
considerable disorder. Besides its effect in distending the alimentary 
canal and blood-vessels through which it passes, it further accelerates 
the retrogressive transformation of the blood and textures, as is mani- 
fest by the increase of matter excreted by the kidneys and intestines. 
(Bocker, ut supra.) It appears, therefore, that water largely taken 

1 Long experience has fully convinced me of the danger of an empirical mode of treat- 
ment in the worst forms of delirium tremens. I have known more than one instance 
where death has speedily and unexpectedly ensued upon the administration of opium in 
large doses, ordered to be "repeated until sleep should be procured." When it was 
procured, it proved to be the sleep of death. Inability to sleep, in this disorder, depends 
upon the exhaustion of the medullary and nervous powers, as named above, and perhaps 
also somewhat on the vitiated state of the blood, which gets loaded with decaying and 
excrementitious matters that the depressed secerning energies are not able to eliminate. 
Here stimulants, instead of increased narcotization, are the things needed; and even 
tonics may be of service, combined with nutrients in the form of soups, jellies, and fa- 
rinaceous foods, and also diuretics and aperients. These should be given during the 
day, and the opiates reserved for the night; and even moderate doses, under such cir- 
cumstances, often prove to be efficacious. I have sometimes found better results fol- 
low from the use of tincture or extract of Indian hemp (which, however, are not always 
obtainable of definite strength) than from that of opium, for it calms the nervous system 
and induces sleep, without impairing the appetite or powers of digestion. The tincture 
of hop, too, is a useful adjunct to other remedies in this point of view. 



58 EXCITING CAUSES OE DISEASE. 

tends to reduce the weight of the body, and impoverishes the blood, 
whilst alcoholic liquors have the opposite effect. 

57. Disease may be excited by unwholesome articles with which the 
food is adulterated. To this class of causes belong various poisons ; 
the operation of some of these will be noticed under the head of Modes 
of Death (see chapter on Prognosis ;) but for further details, works on 
toxicology and materia medica must be consulted. There are some 
noxious matters occasionally mixed with food, which produce delete- 
rious effects very gradually. In this way salted provisions, too long 
used, cause scurvy: ergotted corn has been known to produce dry gan- 
grene. Lead gradually introduced into the system causes constipation, 
colic, paralysis, cachexia, anaemia and atrophy. Impure water used 
as drink, is a common cause of disease. River or pump water near 
towns often contains decaying vegetable or animal matters, and induces 
sickness, diarrhoea, dysentery, cholera, and typhoid symptoms. Hard 
waters, which are impregnated with some of the salts of lime, render 
the bowels costive, and are supposed to favour the production of cal- 
culous diseases and bronchocele: brackish waters, containing saline 
matter, may induce dyspepsia and diarrhoea: chalybeates, containing 
iron, are constipating and heating. — Any kind of impure water, if long- 
used as drink, may gradually impair the processes of digestion, nutri- 
tion, and assimilation, even although no obvious disorder immediately 
results from their use. 

Under the head of non-alimentary ingesta which may cause disease, 
we must reckon various medicines : and that not only when injudiciously 
administered, but even as commonly prescribed: the remedies necessary 
to cure or relieve many diseases are not uncommonly necessary evils; 
they remove one disorder by inducing another, and it is well when the 
evil thus induced is the smaller of the two. It cannot be denied that 
proofs are frequently met with of the mischievous and morbific effects 
of the injudicious employment of drugs, and there can be no doubt that 
many of the boasted achievements of homoeopathy, and other quacke- 
ries, are really the result of the suspension of the influence of injurious 
medicinal agents. 1 

58. (b.) Unfitness in the quality of aliment is another condition 
whereby ingesta may cause disease. Man is by nature and habit an 
omnivorous animal ; and in general his health is best maintained by 
an admixture of different qualities and varieties of animal and vege- 
table food. The insalubrity of the simpler constituents of food, when 
used separately, even those supposed to be most nutritive, has been 

1 Dr. Mann in revising these pages has favoured me with the following illustration: — 
"A very interesting case of this kind has just fallen under my notice. I was called last 
week to see a physician, a visitor to this place (Cromer,) for relaxation. I found him 
in a state of great nervous excitement and trepidation, and full of the idea that he was 
just going into a state of collapse. On investigating the facts I found he had been 
taking immoderate exercise in the sun, and eating lobsters and drinking pale ale, until 
attacked with bilious derangement, and miid continued fever; then he fancied he had * 
suffered from malaria, and that the fever had distinct intermissions, so he dosed himself 
with quinine. When I saw him he had taken sixty grains of disulphate of quinine in a 
few hours; the nervous derangement was unquestionably due to the influence of the me- 
dicinal agent. It was four complete days before the disease thus induced had disap- 
peared." 



INFLUENCE OF ALIMENTARY ELEMENTS. 



59 



well shown by the numerous experiments of Majendie, Gmelin, and 
others. They fed dogs, geese, donkeys, and other animals, on articles 
which are generally considered highly nutritive, as sugar, gum, starch, 
oil, or butter: when any of these were given exclusively, the animals 
died with symptoms of starvation almost as soon as if they had been 
kept without food. Even bread, when too fine, is unsuitable for exclu- 
sive nutriment. A dog fed on pure white bread lived only fifty days, 
whereas another fed with the coarsest brown bread was well nou- 
rished," and seemed capable of living an indefinite period. According 
to the researches of a commission of the French Institute, (the report 
of which was published in 1841,) animals fed on pure fibrin, albumen, 
or gelatine, die of starvation, and with reduced quantity and depraved 
quality of the blood, almost as soon as if not fed at all. Gluten, or 
vegetable albumen, seemed to be the only simple principle which was 
able alone to maintain life. The nutritious qualities of vegetable food 
depend chiefly on the quantity they contain of this azotized principle. 
Wheaten bread consists of this highly nutritious principle combined 
with a due proportion of combustible and heat-supplying starch. Hence 
it is the most sufficient and useful of all the varieties of food, and may 
therefore well be called the staff of life. Even animal albumen and 
fibrin require mixture with vegetable matter to make them properly 
nutritious as well as wholesome ; and gelatine and oily matters are 
still less available for nourishment without some such combination. In 
the experiments just alluded to, animals could be supported for a 
lengthened time on meat or flesh, which comprises several of the ele- 
mentary principles, although they could not be sustained by any one 
of these principles given alone. 

The utility of a due combination of the organic elements in the food 
used by animals was long since sagaciously pointed out by Dr. Prout, 
who takes the natural aliment of infancy, milk, as the great type of 
all proper kinds of nourishment ; as it contains albumen, oil, sugar, 
and water, (not omitting certain salts, especially the chloride of sodium, 
and phosphate of lime,) so all other kinds of food ordinarily used for 
sustenance ought to include these elements, or others isomeric (that is, 
identical in ultimate composition) with them; and it is certainly true 
that all combinations of food sanctioned by custom do comprise such 
ingredients. Bread contains two of them, gluten, which is vegetable 
albumen, and starch, which is isomeric with sugar; but bread is not 
relished without butter or some fat with it. Neither does meat, which 
contains albumen and fat, suit the taste without combination with 
bread, rice, potatoes, or some vegetable, which represents the amyla- 
ceous or saccharine principle. The palate likewise craves the addition 
of a little salt, which promotes the digestion and assimilation of most 
kinds of food. 

59. Much discussion has occurred of late as to the share which each 
of these constituents of food takes in the actions of the animal 
economy, and the extent to which they can be changed by the process 
of digestion and assimilation. Dumas, and the French chemists gene- 
rally, have maintained that the digestive process only separates and 
appropriates principles ready formed in the food, and that it does not 



60 



EXCITING CAUSES OF DISEASE. 



effect the conversion of one into another. Thus they say that all the 
albumen or fibrin in the body is derived from the albumen or gluten of 
the food ; and all the fat from fat or oil contained in the nourishment. 
This view, so far as fat at least is concerned, is opposed by many fami- 
liar facts, such as the fattening of domestic animals with farinaceous and 
vegetable foods, which contain very little fat; and it has been com- 
pletely negatived by the experiments of Petroz and Boussingault, which 
have proved that geese and pigs during the process of fattening gain 
more fat than is contained in their food. 1 It further appears probable 
that the conversion of sugar into fat is promoted by the agency of bile; 
for H. Meckel found that by keeping a mixture of bile and grape sugar 
at a warm temperature, the quantity of fat in the mixture increased 
to double in five hours, and more than treble in twenty-four hours. It 
is pretty certain, therefore, that fat may be formed out of starch or the 
saccharine principle, and probably from the albuminous also, as albu- 
men gets spontaneously converted into fat under special circumstances. 
But there is no decisive evidence to show that albumen or gelatine is 
elaborated from fat, starch, or sugar, at least under common circum- 
stances; and it is certain that these elements alone do not suffice to 
sustain animal strength or life. 2 

Baron Liebig, has, in a very comprehensive hypothesis, suggested 
that food not only supplies the plastic constituents whereby the waste 
of the textures is repaired, and their growth supplied, but that it also 
furnishes the chief combustible principle of the blood, which is burned 
under the process of respiration for the support of the animal tempera- 
ture, and thus protects the histo-genetic (or tissue-making) materials 
from being consumed. Thus whilst albumen, fibrin, and analogous 
matters are applied to the purposes of growth and nutrition, oil, sugar, 
starch, alcohol, and allied matters, like gum and vegetable acids, con- 
stitute merely combustive material, or fuel, which is converted, through 
the oxidating processes of respiration, into carbonic acid and water, 
giving out heat during the change. It is certain, however, that fatty 
matter is, in a degree, essential to nutrition, being a constant consti- 
tuent of the nuclei and granules of the primary cells of tissues and of 
nerve substance. So also as starch and sugar are susceptible of being 
converted into fat by the agency of the liver, they cannot be excluded 
from the list of nutritive materials. It is scarcely possible to doubt 
that the increase of weight and muscular strength that accrues from 
the continued employment of cod-liver oil can be anything else than a 
result of direct nutrition by means of oil. 

60. The chief alimentary matters may be classed into groups, ac- 
cordingly as they are albuminous, gelatinous, oleaginous, and saccha- 
rine, or amylaceous : we have now briefly to consider how an excess, or 

1 Dr. Day's Eeport on Chemistry in Dr. Banking's Abstract, July, 1846, p. 316. 

2 In a Tery able paper on Vital affinities, by Dr. Alison, (Transac. of Royal Soc. Edin. 
1817.) many arguments are adduced in favour of the inference that albumen may be 
formed in the animal body, especially in vigorous health: the author suggests that am- 
monia may be the source from which starch and other non-azotized articles of food re- 
ceive the azote that is necessary for their conversion into albumen. There is much 
reason on the side of this notion; it may be seen that I have long entertained a similar 
opinion in regard to the conversion of gelatine into albumen. 



ALIMENTARY ELEMENTS 



Gl 



defect, and in some instances faulty quality, of either of these, may 
operate in causing disease. 

Albuminous pr protcinaceous articles, such as the lean of meat, fowl, 
and fish, gluten of oread, and casein of milk, supply the albumen and 
fibrin of the blood, and of the textures of the body. Hence deficiency 
of this kind of nourishment will produce, first, weakness of the heart and 
other muscles, and then wasting of these, and of other textures, with 
diminution of the quantity and richness of the blood. Failure of mus- 
cular strength, weakness of the circulation, and wasting of the muscular 
and other structures, commonly result from insufficiency of albuminous 
foods. Excess of carneous food, particularly of the richer kind, butcher's 
meat, tends to oppress and derange the digestive organs, or to cause 
plethora, with excited circulation and feverishness, which may even 
result in hemorrhage, inflammation, gout, lithiasis, &c. 

Bad quality of albuminous food is peculiarly injurious to persons of 
weak digestive and assimilative powers: thus the casein of cheese, the 
fibrin of stale or salted meats, and the gluten of sour or ill-baked bread 
or heavy pastry, may irritate the alimentary canal and cause dyspepsia 
and diarrhoea, and even when absorbed, instead of forming good protein 
material, may degenerate into certain products of animal decay, 
namely, lithic and lactic acids, urea, 1 &c. Hence may arise gout, 
rheumatism, calculous disorders, cutaneous eruptions, low irritative 
fever and cachexia. 

Gelatinous foods, soups, broths, isinglass, and jellies, are by no 
means so nutritious as albuminous matters ; but when combined with 
bread they satisfy hunger and nourish the body so well that it seems 
very probable that in a healthy constitution gelatine may assist in the 
formation of albumen; but when used in excess, or to the exclusion of 
bread and meat, it ceases to be nutritious, and the strength and flesh 
waste under its use. 

Oleaginous nutriment, butter, fat of meat, oils, and oily seeds, not 
only supply the material for the adipose textures of the body, but also 
assist in the formation of other structures and secretions, (oil globules 
forming a normal constituent in them,) and afford the strongest fuel 
for the maintenance of animal heat by respiration. From what has 
been before stated (§ 59,) it may be inferred that fat may also be 
formed from saccharine and starchy food, as well as drawn from the 
storehouses of the adipose membrane: and from the researches of M. 
Claude Bernard it appears that the liver has the power of elaborating 
both fat and sugar out of the constituents of the blood when neither of 
these principles is supplied in the food. 2 Still deficiency of fat in the 
food has been observed to induce the following morbid results: loss of 
flesh, and of the rounded plumpness and smoothness of the surface, 

1 In this statement I disregard the dogma of Liebig that the materials of food serve 
for respiration and nutrition only, and that urea, lithic acid and excrementitious matters, 
are derived from the decay of the tissues alone. Daily observation convinces the medi- 
cal practitioner that in persons of weak assimilation, certain articles of food, so certainly 
and promptly cause an increase of animal matter in the urine, that there can be no doubt 
they are the'direct sources of the addition. The observations of Lehmann support the 
same conclusion. — Physiohgical Chemistry; translated by Dr. Day, 1851, vol. i. p. 161* 

2 L' Union Medicale, 1850. 



62 



EXCITING CAUSES OF DISEASE. 



■which "becomes skinny, wrinkled, and often dry and scurfy; brittleness 
of the hair and nails ; deficient secretion of mucus at the orifices of 
mucous passages, of cerumen in the ear, and of synovia in the sheaths 
and joints; insufficient formation of bile, and consequent impaired 
digestion and flatulent fetid and irregular feculent excretion; with 
diminution of the power of sustaining animal heat. On this account 
the privation of oily food is more injurious in cold seasons and climates 
than in the reverse, often even aggravating the morbific operation of 
external cold. Excess of fat food may disorder the stomach by its 
indigestibility, becoming rancid, and causing heartburn or sickness, 
and sometimes a bitter bilious taste ; for much fat seems to induce a 
regurgitation of bile into the stomach, probably to assist its digestion 
(Beaumont) and absorption (Matteucci.) If the fat is carried into the 
blood, it may cause inconvenient obesity by its accumulation in the 
adipose texture of various parts of the body; or if the subject be natu- 
rally lean, and incapable of accumulating fat, the superfluity must be 
got rid of, and the natural emunctories, the sebaceous follicles of the 
skin, and the liver, then become disordered; hence appear acne and 
other follicular diseases of the skin, and various bilious disorders. 
These results are the most readily produced in sedentary persons, in 
whom the exercise of the lungs is insufficient to consume the superfluous 
fat. On the 'contrary, those who use active exercise can often take 
considerable quantities of fat with impunity, and sometimes with ad- 
vantage. For similar reasons, oily food is better borne in cold than 
in hot climates and seasons: thus, as Liebig has pointed out, the Lap- 
lander relishes train oil, which serves to sustain the warmth of his body ; 
whilst the Italian in a sunny climate prefers the less combustible food, 
maccaroni and fruit, which nourish without heating. The Esquimaux 
surprise travellers by the enormous quantities of blubber that they can 
consume ; but the Indian is easily satisfied with rice and other light 
farinaceous vegetables. 

The quality of oily matter in the food is an important element in its 
morbific effects; such substances as are most prone to chemical change, 
or to become solid, are more likely to disagree than others. Thus stale 
or tainted butter or fats, and rancid oils, are peculiarly offensive to 
the digestive organs, both on account of the production of injurious 
acids (butyric and oleic,) and because their thickness renders them in- 
capable of the minute division necessary for their absorption and ap- 
propriation by nutritive process. On the other hand, cream, fresh 
butter, mild fat, and sweet salad oil, agree well and nourish, especially 
when intimately blended with farinaceous or succulent vegetable mat- 
ters: and the cod-liver oil, when fresh and free from rancidity, is 
borne by the weakest stomachs. It is possible that the easy digesti- 
bility of certain fats is partly due to the facility with which they form 
emulsions with the pancreatic and other secretions of the alimentary 
canal. Thus cod-liver oil and the fat of bacon are among those most 
easily borne on the stomach, and I am informed by Dr. Lyon Playfair 
that these both possess the important property of saponifying with the 
alkaline carbonates, whereas other oils unite only with caustic alkalies. 

Amylaceous or starchy foods, such as arrowroot, sago, tapioca, and 



ALIMENTARY ELEMENTS. 



63 



many kindred farinaceous preparations, although isomeric (i. e. consist- 
ing of the same elements) with saccharine matter, are not quite similar 
in their physiological effects. Like it. they probably supply a fuel for 
the process of respiration, rather than sustain the body by nourish- 
ing the textures, and so save them from the consuming influence of the 
oxygen absorbed through the lungs ; and if taken in excess, they may 
either lead to the formation of fat, (§ 59,) which is deposited in the 
textures, or passing into fermentation, they may give origin to acetic, 
lactic, and oxalic acids, and other matters of an injurious kind; this 
latter effect occurs more often with saccharine than with amylaceous 
food. On the alimentary canal too their effects in some degree differ, 
excess of amylaceous food impairs the action of the intestines and the 
secretion of the liver, whereas sweet things often relax the bowels and 
cause a redundancy of bile. These different effects of saccharine food 
are probably connected with its occasionally containing, or forming, 
vegetable acids, which irritate the alimentary canal, and which may 
thence cause dyspepsia, diarrhoea, diabetes, rheumatism, oxaluria, and 
other disorders of the same class. 

Amylaceous and saccharine matters being the mildest materials of 
food, serve to dilute the stronger articles fibrin and oil, and to render 
them both more palatable and more digestible ; when, therefore, the 
former are deficient, the latter are more apt to disagree, and to fail to 
nourish. In common with other vegetable principles, such as gum, 
vegetable jelly, extractive, &c, they also contain alkalies combined 
with vegetable acids, compounds which are decomposable in persons 
of strong digestion, the alkali then becoming useful in counteracting 
the acidity which results from the processes of transformation con- 
tinually proceeding in the body. On this account fruits, and other 
vegetables, assist in neutralizing and eliminating lithic acid, and in 
preventing the occurrence of gout and gravel. This view is in accord- 
ance with the statements of Prout, Liebig, and Wohler ; but I believe 
it only applies to the case of persons whose digestion is strong; for 
where this is weak, I find that vegetable acids and fruit commonly in- 
crease the acidity of the urine, and are therefore injurious: 1 whether 
they do this by passing unaltered through the circulation, or by irri- 
tating the primse vise, and thus leading to an usual development of hy- 
drochloric and other unchangeable acids, I cannot say, but the latter 
course would appear to be the most probable. But there is some 
reason to suppose that vegetable acids have an influence on the blood 
before or while they undergo the combustive process; for whether alone 
or in combination with an alkali, they certainly exercise an operation 
on the body more cooling and antiphlogistic than can result from the 
alkalies which they contain. Thus sub-acid fruits and drinks are found 
refreshing and really cooling in fevers ; and lemon-juice even in large 
quantities is now generally acknowledged to be powerfully antiphlogistic, 
especially in rheumatic and gouty inflammation. That this property 
depends on an eliminating power of the vegetable acids and of their 
salts is possible, but it may be connected with some direct chemical 

1 This has been confirmed by Dr. Bence Jones, ■who found that large doses of tartaric 
acid render the urine more acid than usual. — Phil. Trans., 1849. 



64 



EXCITING CAUSES OF DISEASE. 



action by which the materies morbi in the blood is decomposed and 
thus deprived of its irritating influence. 

61. The selection and combination of articles suitable for food would 
be a difficult task, requiring much scientific knowledge and calculation, 
were it not that Nature has supplied us with a trustworthy guide, which 
happily points out the varied wants of the system in changes of season 
and diversities of circumstance. The appetite and taste generally in- 
struct us pretty safely as to what are the best proportions in which the 
different kinds of food should be mixed ; but they must not be per- 
verted and pampered by condiments and refined modes of cooking. 
These expedients coax and deceive the appetite and taste; and if these 
guardians of the nutritive department are cheated, it is no wonder that 
the department itself becomes deranged. 

62. (<?.) Aliment may be excessive or deficient in quantity. Some- 
times the appetite is inordinate ; more frequently it is stimulated and 
tempted by luxuries; in either case, more food is apt to be taken than 
the expenditure of the system requires. If the digestive organs fail 
to dispose of this, they become distended, irritated, and otherwise dis- 
ordered by the undigested part, and the various symptoms of indi- 
gestion appear, or perhaps oppressed breathing, palpitation, congestive 
and convulsive attacks, gastritis, enteritis, colic or diarrhoea. If the 
digestive organs are strong, and digest the excess of food, they send 
too much chyle into the blood, which then over-distends the vessels, 
and deranges the functions of assimilation; hence may result plethora, 
apoplexy, gout, gravel, or some congestive hemorrhage or inflammatory 
disorder, to which the individual may have been predisposed (§ 14.) 
Such evil consequences of repletion ensue the more readily in sedentary 
persons, in whom the waste of the body is small, and the excretions 
are scanty. 

63. Defective nourishment excites various disorders. In the extreme 
case of absolute privation of food the cravings of hunger alternate with 
nausea, and a sense of sinking: then follow extreme depression, tran- 
sient fever, delirium, general disorder of both body and mind, increasing 
feebleness, and inability to maintain animal heat. It is a curious fact, 
that in this state the stomach sometimes becomes inflamed; probably 
from the irritating action of its own secretion on the unrelieved vessels. 
Even in the slighter degrees of abstinence, enjoined by the physician 
in the treatment of disease, symptoms of vascular and nervous irrita- 
tion often arise in the midst of general weakness. By many practi- 
tioners of the Broussaian school, these symptoms are erroneously taken 
to be indications for greater rigidity in the antiphlogistic plan, whereas 
a judicious and cautious return to a nourishing diet is really required, 
and will prove the best cure. Deficiency of food ultimately causes 
general weakness of the functions and wasting of all the textures, but 
least of those of the nervous system. The blood becomes thin and 
easily extravasated ; the gums spongy and bleeding ; fat disappears ; 
the muscles get thin and flabby; the legs become ©edematous ; diarrhoea 
often occurs ; ulcers appear in the cornea, and other parts which are 
the least vascular ; and a state of scurvy, or cachexy, is induced, from 
which an improved diet may now fail to restore ; for the powers of di- 



EXCESSIVE BODILY EXERTION. 



65 



gestion and assimilation sink with the other functions, and it is only 
by very gentle and careful management that they can be reinstated 
■when very far gone. Another result of the general depression caused 
by inanition is the impairment of the action of the excretory glands, 
in consequence of which effete and decayed matters which ought to be 
thrown out of the system are retained, and produce fetid breath and 
offensive effluvia, as observed in persons who fast long or are ill fed. 
Doubtless, too, the lowered vitality of the tissues then renders them 
little able to resist the tendency to decomposition, and hence there is 
ready decay and interstitial absorption. Chossat found that in ani- 
mals gradually starved to death the temperature progressively declined, 
so that unless it were maintained artificially, the animals seemed to die 
of cold. All the textures, even the bones, sustained great loss of weight ; 
but the substance of the nervous centres wasted far less than that of 
any other organs. This fact I should be inclined to attribute to the 
peculiar condition of the blood-vessels supplying these centres, which 
enables them to monopolize the little blood remaining ; in this we find 
a ready interpretation of the predominance of nervous symptoms in 
persons suffering from inanition. (See Anaemia.) In less extreme 
cases, poor living may excite scrofulous and tuberculous disease, and 
other kindred forms of degeneration of organs. The bad influence of 
poor living is much more expressed in those who are confined in close 
habitations, such as prisons, poor-houses, the cabins of ships, and be- 
sieged towns, than in those who are at large (§ 22 :) and it is under 
such circumstances that the insalubrity of some kinds of food, however 
nutritious in general, becomes apparent. Thus even bread, with meat, 
or broth, will not preclude the occurrence of scurvy; but a sufficient 
addition of fresh vegetables, even if they be only potatoes, prevents 
this disease from appearing. — (Dr. Baly, Med. Gaz., Feb. 1843.) It 
has been observed that pestilential diseases of the most destructive 
kinds ensue after a period of famine. It is the ill-fed of the popula- 
tion that mainly succumb to epidemic, endemic, and infectious disor- 
ders. Dr. Carpenter well suggests that this may be at once explained, 
when it is remembered that in the body during starvation there is, not 
merely that general depression of vital powers which may be a predis- 
position to almost any kind of malady, and pre-eminently to such as 
are of a zymotic nature, — but also the presence in the blood of an un- 
usual quantity of disintegrating matter, which forms the most favour- 
able nidus for the reception and reproduction of morbific poisons. — 
(Principles of Human Physiology, 4th Edit., 1853, p. 39T.) 

64. (4.) Excessive bodily exertion is a common exciting cause of 
disease. General muscular efforts, as in running, walking up hill, 
rowing, &c, hurry the movement of the blood back to the heart, and 
resist its distribution through the arteries to such an extent that the 
heart, the lungs, the brain, and other organs, have an unusual pressure 
upon them (§ 51.) Disease is then readily induced, especially in per- 
sons little accustomed to this kind of exercise (24.) 

The heart, when excited to inordinate action, is often strained and 
distended, and its function, or even its structure, as well as that of the 
5 



66 



EXCITING CAUSES OF DISEASE. 



great vessels, may be impaired in consequence. This is especially apt 
to happen if there be anything already wrong in the structure of the 
organ, its valves or vessels ; and independently of actual disease there 
are naturally very various degrees of perfection and strength in these 
parts. 

The brain is particularly liable to suffer from violent exertion, espe- 
cially if joined with a stooping or constrained posture; for its vessels 
are not, like those of the limbs and trunk, supported by muscular pres- 
sure, and the excited heart on this account sends its blood into them with 
more force. Hence confusion of the senses, giddiness, noise in the 
ears, deafness, defective vision, convulsions, palsy, and apoplexy, are 
sometimes brought on by violent exertion. 

The lungs too are apt to suffer; for the blood being returned to them 
faster than they can arterialize it, they become greatly congested 
cough, dyspnoea, haemoptysis, or inflammation of the lungs, ensue in 
this way: the texture of the lungs sometimes also sustains injury in 
consequence of the violent strain to which it is subjected by the in- 
creased exertions made in sustaining the breathing, and temporary 
emphysema is produced. 

Other internal organs are sometimes disordered by the blood thrown 
into, or retained in, their vessels by the pressure of external muscular 
action. Derangement of the liver, hsematemesis, hemorrhoids, and 
hematuria, have been brought on by such means. The sharp pains or 
stitches felt in the sides or abdomen on running fast are commonly sup- 
posed to be in the liver or spleen: but more probably they are spasms 
of the intestines — temporary colic, — produced by irregular pressure on 
them, when their sensibility is raised in consequence of an undue 
quantity of blood being thrown into them. 

Some kinds of muscular exertion peculiarly affect certain organs. 
Thus loud reading, or speaking, or blowing wind instruments, especially 
tries the organs of respiration and voice, and may cause hemorrhage, 
inflammation, and various diseases of these structures. Excessive or 
rough riding or leaping may injuriously affect the kidneys and organs 
of generation. Straining to lift a heavy weight, or at stool, or in any 
continued effort, which implies holding the breath, endangers the struc- 
ture of the vessels of the chest and brain, on which there is no equally 
counteracting muscular pressure exerted at the time. 

Long continued bodily exertion may also cause disease by its ex- 
hausting effects. In extreme degrees this exhaustion may amount to 
syncope, and even death: short of this, it may cause great weakness of 
the muscles and of the heart, with corresponding depression of other 
functions, congestion of the viscera, and defective assimilation and ex- 
cretion : hence arises the low typhoid, or adynamic fever, which some- 
times follows prolonged fatigue. In these cases the chief disorder must 
be considered to be in the blood, which becomes loaded with the de- 

1 Some of the most severe cases of pneumonia that I have ever had to treat have occurred 
in boys at public schools after violent and long-sustained exertion at football, and other 
athletic games. These cases all closely resembled each other, being eminently conges- 
tive, and accompanied by much depression in the early stage, and generally affecting 
both lungs; yet in spite of the formidable character and extent of the disease in these 
cases, they have in almost every instance recovered. 



WANT OF EXERCISE — MENTAL EMOTION. 



67 



caying matters that result from the disintegration of the muscular and 
other tissues, and which takes place more.rapidly than the antagonistic 
processes of elimination and reparation. In slighter cases of great 
fatigue there are giddiness, faintness, nausea, loss of appetite, indiges- 
tion, costiveness, amenorrhoea, and other varieties of injured function. 
When muscular exercise is carried on so long, or to such a degree, as 
to impair the organic functions, it thereby induces disorder in them in 
addition to the weakness, prostration, and actual suffering in the ani- 
mal functions. A serious part of such disturbance is the sleeplessness 
which, in extreme fatigue, brings the patient into a state nearly re- 
sembling delirium tremens. This, as we have already mentioned when 
speaking of predisposing causes (§ 23,) is mainly due to the state of 
the respiration, which being insufficiently maintained by the weakened 
spinal function, is aided by continued voluntary efforts, manifested in 
the frequent sighing that takes place. In these conditions diffusible 
stimulants are the best hypnotics. 

65. The opposite extreme, want of exercise, is capable of exciting 
as well as predisposing to disease (§ 24.) Thus internal congestions, 
deficient and disordered secretions, general plethora, over nourishment 
of adipose texture, and wasting of muscles, besides various evil conse- 
quences of these morbid conditions, may result from this cause when 
in prolonged operation. If combined with some of the other disturbing 
influences noticed in this section, it is a still more ready and common % 
cause of mischief. Some organs suffer more particularly from a seden- 
tary mode of life ; for example, the liver, in consequence of the increased 
task of decarbonization of the blood, which deficient respiratory exer- 
cise throws on it: 1 the brain, from its direct and free communication 
with the centre of the circulation, which exposes it to an accumulation 
of blood when the distant circulation fails: hence bilious disorders, 
dyspepsia, hemorrhoids, headache, and giddiness, &c. 

66. (5.) Excessive mental emotion or exertion, and acute sensation, 
are common causes of disease. Closely knit together as the mind and 
body are, it is not surprising that they should ever be ready to affect 
each other, and that when the bodily impression is strong, the mental 
affection should be found to be not slight nor transient. The heart 
suffers most remarkably in this way. Thus a sudden shock, whether 
of grief, surprise, fear, or even joy, may cause fainting, (partial sus- 
pension of the action of the heart:) nay, even death has ensued; and 
the expressions "frightened to death," and "killed with joy," are not 
always mere figures of speech. Sudden acute pain often causes faint- 
ing. Palpitation and irregular action of the heart are very common 
effects of emotion. The pallor of the face, and coldness of the extre- 
mities and surface, that result from strong mental disturbance are in- 
dications of the manner in which the circulation is deranged under such 
influences, and these are almost always attended with a corresponding 
amount of internal congestions, leading to disturbance of the functions 

1 When there is more hydro-carbonaceous matter in the blood than can be burned off 
through the lungs, it is saponified by the liver, and thrown out as bile through the intes- 
tines, although in normal states the bile itself is burned away by the respiration. 



68 



EXCITING CAUSES OF DISEASE. 



of various organs, manifested in spasms, hemorrhages, fluxes, and other 
like affections. 

Other organs also suffer under strong moral impressions. Spasmo- 
dic asthma, and spasmodic affections of the throat and stomach, are 
sometimes thus induced. Apoplexy, palsy, inflammation of the brain, 
chorea, epilepsy, catalepsy, and insanity, have been caused by exces- 
sive anger, terror, surprise, and joy. 

Mental emotions commonly affect the secreting organs, and especially 
influence the functions of the alimentary canal. A piece of very bad 
news takes away appetite, or impairs digestion. Fright or anxiety 
often loosens the bowels, or brings on a bilious attack, or jaundice. 
The uterine periodic function is remarkably subject to the influence of 
moral emotions, and many of its disorders may often be traced to this 
source. The secretion of the breasts is well known to be easily affected 
by emotion ; it is increased by the pleasurable feeling of maternal fond- 
ness, and diminished by anxiety, distress, or even joyous excitement, 
and rendered depraved, so that it disagrees with the infant when the 
mother is suddenly shocked. There have been cases in which under 
such circumstances the milk has seemed to act even as a positive poison 
to the child. 

The less vivid emotions of the mind, and over-exertion of its faculties, 
are also sometimes exciting causes of disease. Long-continued depres- 
sion or anxiety often induces dyspepsia, costiveness, or diarrhoea, asth- 
ma, and functional disorders of the heart, liver, and kidney, menorrha- 
gia, and dysmenorrhoea ; and structural diseases of the same parts oc- 
casionally follow these functional affections. In a large proportion of 
the cases of degenerative disease of the kidneys and heart that have 
fallen under my notice, the most obvious exciting cause of the mischief 
has been extreme anxiety, or long-continued mental exertion. There 
is generally an outward sign of the change manifested in the arcus or 
circulus senilis of the eye ; this almost always indicates premature age 
brought on by the wear and tear of excessive mental anxiety or labour, 
or by "fast living." The influence of mental anxiety and exertion on 
the function of nutrition is proverbially illustrated by the expression 
"worn to a shadow;" and the decaying process may be observed in 
the large amount of urea, lithates, phosphates, and other results of 
animal decomposition contained in the urine under these circumstances, 
actually constituting a form of diabetes ureosus, or azoturia. Over- 
exertion of the faculties, or excitement of the passions of the mind, tells 
chiefly on the mind and the nervous system. In this way often arise 
congestions of the brain and exhaustion of nervous power, giddiness, 
stupor, headache, dull and disordered sensation, and even apoplexy 
and palsy. Or the disorder may be inflammatory, with symptoms of 
irregular excitement, nervousness, delirium, tremor, convulsion, partial 
paralysis, &c. Sometimes the effects of excessive mental exertion 
or moral emotion are only apparent in mental phenomena, the powers 
of the mind being so injured or disordered that various forms of in- 
sanity are produced. When we consider the variety and amount of 
employment and excitement (food and condiment, so to speak) that 
pass into the minds of persons in the busy and worrying scenes of 



MENTAL EXERTION — EXCESSIVE EVACUATION. 



69 



civilized life, it is not extraordinary that its functions, as well as the 
digestion, or any other vital action, should occasionally get deranged. 

67. (6.) Excessive evacuation or loss either of blood or of some se- 
cretion, has been already noticed (§ 28) as one of the causes of debility, 
which then predisposes to disease; but if the loss be great or sudden, 
it may produce immediate disease itself. A certain fulness of the 
heart and blood-vessels is required for their healthy action, as well as 
for the support of all the organs which they supply. If a moderate 
quantity of blood be suddenly withdrawn, or a large quantity less sud- 
denly, the heart's action is impaired, rendered irregular, and perhaps 
interrupted, and the brain not receiving a sufficient current for the 
maintenance of its functions, fainting may follow, with loss of con- 
sciousness, accompanied, or succeeded, by palpitation, delirium, convul- 
sion, or even death. The sudden impression in these cases is more 
marked on the brain than on the heart; for the same effects may be 
induced by the loss of a much smaller quantity of blood in an erect or 
sitting, than in a horizontal posture. Similar results have been found 
to ensue in consequence of the sudden removal of pressure from the 
vessels in any considerable part of the body, as by the discharge of 
the fluid of ascites, or by enclosing a limb in an exhausting tube. 
(Dr. Arnott.) Lower mentions a case of extensive varix (enlargement) 
of the veins of the lower extremities, in which the patient could not 
stand without fainting, until the legs were bandaged. In these cases, 
much of the blood, although not removed from the system, gravitates 
into the enlarged vessels, and becomes unavailable for the general cir- 
culation. The fainting which occurs is called cerebral syncope, because 
the functions of the brain are suspended; consciousness is lost before 
the heart's action is interrupted; but the disorder of the brain reacts 
on the heart, and thus adds another cause of impairment of its own 
action. This is Dr. Alison's explanation. On the other hand, if the 
hemorrhage is gradual, and the posture horizontal, other functions fail 
before the consciousness is lost — the chief symptoms being "feebleness 
of muscular action, paleness and collapse of the countenance, coldness, 
beginning at the extremities, cold sweat, commencing on the face, the 
pulse imperceptible," and the heart's action failing. The true nature 
of these effects, and of the reaction and nervous symptoms by which 
they are often followed, will be considered hereafter in connexion with 
the subject of anaemia. 

Not only blood-letting and hemorrhages, but other evacuations, such 
as purging, sweating, vomiting, and excessive catamenial and seminal 
discharges, are capable of producing syncope and general debility. 
The depression and faintness induced by these, although less prompt, 
are often more permanent than are those from blood-letting ; for such 
evacuations imply, not only reduction in the mass of blood, but also 
exhaustion of the vital energies of the secretions and actions concerned 
in producing them. 

The diseases gradually induced by these several causes of evacuation 
are seldom of a simple kind. General weakness of the muscles and 
functions is a common result; but this is often complicated with symp- 



TO 



EXCITING CAUSES OF DISEASE. 



toms of partial reaction, palpitation, spasms, noises in the head, spec- 
tral images, pains in different parts, sometimes very acute, but seldom 
long fixed, partial paralysis, and a defective and disordered state of 
the excretions. 

68. (7.) Deficient evacuation of excrementitious matter, whether ha-, 
bitual or accidental, is a very fertile source of disease. Its morbific 
influence is however considerably diversified. Sometimes it causes dis- 
ease by the positively noxious influence of matter retained in the sys- 
tem ; this is the case when it is the excretion of urine and feces that 
is concerned ; at other times, by promoting fulness of the vessels, and 
thus leading to the various disorders commonly consequent upon this. 
To the latter category belongs the sudden suppression of hemorrhages, 
or other discharges which have become habitual, whether they be milk, 
mucus, serum or pus. Deficient excretion from the bowels is a very 
frequent cause of derangement in the health, manifesting itself by an 
entire train of symptoms, such as furred tongue, foul breath, depraved 
appetite, headache, general torpor and weakness, loaded urine, offensive 
perspiration and eruptions on the skin. 

The matter of alvine and renal excretions is essentially pernicious, 
and cannot be long retained even in their natural repositories without 
causing mischief. Feculent matter, when it has reached the large in- 
testine, is still acted on by the absorbents, which take up its more fluid 
parts, and with them, if long retained, fetid matter, which ought to be 
excreted. The solid residue becomes hard and scybalous, and may re- 
main lodged in the cells of the colon, a cause of irritation, distention, 
and obstruction (§ 51.) Sometimes the system then suffers before the 
intestine itself ; but sooner or later this part becomes irritated, colic, 
diarrhoea, and inflammation ensue; and in some instances, where effi- 
cient remedies are neglected, even ulceration and other structural 
changes take place, before the offending matter is dislodged. 

The retention of urine has yet more serious effects. Besides me- 
chanical distention, irritation, inflammation, and rupture of the blad- 
der, which may follow from the constantly accumulating secretion (§ 
61.) the fluid is partially reabsorbed, giving a urinous smell to the 
breath and perspiration, and sometimes causing typhoid symptoms, 
and in extreme cases proving fatal, with the presence of delirium, or 
convulsions, and coma: effusions of serum, containing urea, are then 
found in the brain, chest, and other parts. These effects are more 
commonly produced by suppression than by mere retention ; but, in fact, 
suppression often follows retention : retained urine is prone to decom- 
position (§ 53 ;) highly irritating and offensive matters are formed in 
it, which cause injury to the bladder, rapidly extending up the ureters 
to the kidneys, whose functions then become impaired or destroyed. 
In some cases of the early stage of the severest form of Bright's dis- 
ease, in which the urine was very scantily secreted and highly albumi- 
nous, I have seen typhoid symptoms of the worst character, accompanied 
by a breaking up and partial solution of the colouring matter of the 
blood, with the appearance of pus globules in it; in two instances there 
was effusion of a bloody purulent fluid into the joints a day or two be- 



DEFICIENT EVACUATION. 



71 



fore death: these results will be further noticed when treating of de- 
fective excretion and purification of the blood as an element of disease. 
Checked perspiration is a frequent and fully admitted cause of disease, 
commonly of a febrile, rheumatic or inflammatory nature: the sudden 
suppression of a fetid sweat in the feet, axillae, and other parts, has 
sometimes been followed by such serious disturbance of the health, as 
plainly to indicate that the matter thus retained must be of a highly 
noxious kind. 

The above illustrations relate to extreme cases ; but the attentive 
observer will find that the same causes, insufficient secretion, and in- 
sufficient evacuation of excrementitious matters, in slighter degrees, 
are among the commonest sources of disorder; and it is by effecting a 
restoration of the proper state of these functions, that the almost uni- 
versal domestic remedies, as well as the common pills and draughts of 
the surgery, prove efficacious in preventing as well as in removing dis- 
ease. Many occasions will occur for the illustration of these facts. 

Numberless maladies arise from suppression or irregularity of the 
catamenial discharge, which appears to be blood in a highly carbonized 
state ; it is hence manifest why its excretion gives relief. Diseases are 
not unfrequently excited, or rendered active, at the period of its total 
cessation. Something of the same kind may be said of the secretion 
of milk. The disorders which are thus produced are at first connected 
with local or general plethora ; but eventually the quality of the blood 
becomes depraved in consequence of the accumulation of these excre- 
mentitious matters. 

69. An artificial discharge or diseased secretion, such as proceeds 
from a seton or issue, or from an ulcer or diseased membrane, or an 
unnaturally profuse flow of an ordinary secretion — such as looseness 
of the bowels, if so long established as to have become habitual — cannot 
be suddenly suppressed without great risk of exciting disease. In the 
case of habitual puriform or sanious discharges from setons, issues, and 
old sores, sudden suppression has sometimes given rise to the most for- 
midable symptoms, snowing plainly that a noxious matter had been 
thrown back upon the system : the fear of the occurrence of such ac- 
cidental suppression, which cannot be always prevented, deters me from 
frequently employing these artificial drains in the treatment of dis- 
ease. 1 Habitual hemorrhages, as from the nose or rectum, and the 
practice of periodical blood-letting, cannot be abruptly stopped with 
safety. The maladies which are likely to ensue vary according to the 

1 A patient who had been under my care with organic disease of the heart (hypertro- 
phy and mitral valve lesion) was recommended by another physician to have a seton 
inserted in the left side. Some months subsequently I was summoned to him in conse- 
quence of his having a severe attack of pleuro -pneumonia, of the right side, which su- 
pervened upon a sudden and altogether unaccountable cessation of the discharge from 
the seton. The affection proved intractable, being accompanied by an unusual degree 
of constitutional irritation and depression, and terminated fatally. Collections of pus 
were found in the right lung, and between layers of lymph effused on the pleura. A 
gentleman with chronic phthisis was in the habit of using croton oil freely as a counter- 
irritant upon his chest. Trusting in an imaginary security from this, he upon one occa- 
sion exposed himself to cold whilst a full pustular eruption was present upon his skin. 
The next night he was attacked with rigours, followed by fever and orthopnoea, and sank 
in three days under suppurative bronchitis. 



72 



EXCITING CAUSES OF DISEASE. 



predisposition ; but generally they are connected with local or general 
vascular fulness, or take the form of some disorder of secretion, or of 
the nervous system, directly depending upon disturbances in the cir- 
culation. Congestion of the brain, apoplexy, congestion of the liver, 
various hemorrhages and inflammations, gout, epilepsy, palsy, hysteria, 
hypochondriasis, and mania, may be specified by way of example. 

The suppression, or too rapid removal, of some cutaneous eruptions 
may be looked upon as belonging to this class. The diseases so ex- 
cited are sometimes inflammatory or profluvial, as gout, rheumatism, 
and diarrhoea; sometimes of a more nervous nature, as chorea, epi- 
lepsy, asthma, dyspepsia, and hysteria. 

70. (8.) Defective cleanliness, ventilation, and drainage. — These 
influences might be expected to be very pernicious from what has been 
premised above ; there are few kinds of filth more offensive, few mephitic 
gases more foul, and few descriptions of offal more abominable, than 
those that are excreted from the animal body itself. If, therefore, as 
we have seen, such matters are so very injurious, when not sufficiently 
eliminated out of the body, it is not surprising that they continue to 
be noxious, and may become active causes of disease even after they 
have been evacuated, if proper means be not taken to remove them 
out of the way. The need of self-purification might be inferred from 
the instinctive habits of many animals and birds, which take great 
pains to cleanse themselves and their young, and in many instances 
carefully remove excrements from their nests and habitations. Even 
plants are supposed by some botanists, to exhibit a like provision to 
preserve themselves against self-poisoning, by the constant spreading 
of their roots into fresh soil, that is not contaminated by their own ex- 
creted matter. Yet with strange disregard of these preservative in- 
stincts, and indolent neglect of the plainest dictates of reason, human 
beings continually expose themselves to the evil influence of their own 
accumulated filth, until disease is engendered, and aggravated into 
pestilence, and the usual rate of mortality among the people is doubled 
or tripled. 1 

Although the three particulars, neglect of cleanliness, imperfect 
ventilation, and defective drainage, operate much in the same way, 
and very commonly combine their influence, yet it will be useful to 
consider briefly the mode in which each excites disease, with a view to 
the consideration of remedial measures. 

71. (a) Filth accumulated on the surface of the body, consists of the 
thickened residue of perspiration, mingled with such extraneous dust 

1 Every practitioner of experience has to encounter manifold proofs of the potency of 
these causes in generating and aggravating disease; the profession and public possess a 
valuable collection of testimony on this point, in the following official reports: — 

Report from the Poor Law Commissioners on the Sanitary Condition of the Labouring 
Classes. 1842. By E. Chadwick, Esq. 

Supplementary Report of the Practice of Interment in Towns. 1843. By E. Chad- 
wick, Esq. 

Reports of Commissioners on the State of Large Towns and Populous Districts. 4 vols. 
1844-1845. 

Reports of Dr. Neil Arnott and Mr. Thomas Page on the Prevalence of Disease at Croy- 
don. 1853. 



DEFECTIVE VENTILATION. 



73 



or dirt as may chance to reach the skin. The sweat is peculiarly rank 
and offensive in some persons, especially when accumulated during 
much muscular exertion ; and in some parts, such as the axillae, the 
peringeum, and between the toes, it is combined with an odorous prin- 
ciple, whose disagreeable character would almost seem to have been 
intended by nature to suggest the necessity of frequent ablutions; yet 
how many, and these not confined to the lowest ranks, are "content to 
live in dirt and stink;" and often eventually pay the penalty of their 
filthiness in various cutaneous diseases thereby induced! The accu- 
mulation of filth on the skin also favours the propagation of vermin, 
and of contagious diseases, especially the itch, from which few of the 
" mighty unwashed" are totally free. The same influence also impedes 
free perspiration, and thus leads to the production of rheumatism and 
diseases of the urinary, and other organs, which sympathize with the 
skin. Neglect of cleanliness in clothes and dwellings, even when not 
immediately injurious through the direct contact of filth with the skin, 
may yet become hurtful by contaminating the air. 

72. (b) Defective Ventilation, or insufficient change of the air of 
dwellings, might be considered to readily suggest its proper remedy by 
the feeling of suffocation that is induced ; but it is not always the de- 
ficiency of oxygen, or excess of carbonic acid, that is equal to the pro- 
duction of a stifling sensation, which does most harm : it is rather the 
scanty supply of fresh air which stints the vital processes without sud- 
denly disturbing them ; and the gradual accumulation of foul effluvia 
which slowly poisons without exciting alarm. Persons are gradually 
brought to endure, without distress, the impure air of a close room, 
although to anyone entering from the open atmosphere it may seem quite 
suffocating. Thus in the habitations of the poor, especially in densely 
populated towns, it is not rare to find ten or fifteen persons crowded to- 
gether in one small room, without any other supply of air than that 
which comes through chinks of the floor or window, or that which enters 
when the door is occasionally opened. Amongst the lower classes in 
towns, the dread of cold prevails much more than the desire for fresh 
air ; and except in the height of summer, the solitary window is rarely 
opened; and during the night, when the greatest number are collected 
together, every external opening is carefully closed. During the winter 
the same plan is pursued ; but, if there be then any fire on the hearth, 
a greater amount of ventilation is perforce ensured. 

The habitual want of pure air especially exerts an unfavourable in- 
fluence on the state of the blood, and on the functions of circulation 
and nutrition, causing pallidity of the surface, and imperfect develop- 
ment of the corpuscles and plasma, which, then, instead of contributing 
to the nourishment of the textures, degenerate into scrofulous or tu- 
berculous matter, whose deposition in the internal organs or glands is 
further favoured by the weakness of the circulation. Exercise does, 
in some degree, counteract this effect of impure air: thus Dr. Guy found 
that in the close workshops of a printing establishment, 44 per cent, 
of the compositors, whose employment requires no exertion, fall victims 
to phthisis, while not more than 31 J per cent, of the pressmen, who, 



74 



EXCITING CAUSES OF DISEASE. 



while breathing the same air, use active bodily efforts, do the same. 
This difference is quite intelligible when it is remembered that active 
exercise tends to remove congestions, and to promote excretion, by in- 
creasing and extending the force of the circulation, and to excite the 
respiratory function, so purifying the condition of the blood. Similar 
exercise in pure air has, however, much more salutary effect; for the 
deaths from phthisis among out door labourers do not exceed 25 per 
cent. 

Insufficient ventilation is by no means confined to the habitations of 
the poor. In modern days, when the construction of houses is more 
complete than it was in olden times, there are no longer the latticed 
casements, chinky floors, ill-fitted doors, and above all, the roaring pile 
of burning wood on the spacious hearth, that supplied abundant venti- 
lation to the houses of our forefathers: now, in proportion as houses 
are "well built," every crevice is so thoroughly stopped, that our rooms 
are well nigh air-tight, and when doors and windows are closed, the 
occupants are consequently enclosed in an atmosphere, which is more 
injurious in proportion to the number assembled. Add to this the vi- 
tiating effect of artificial lights, and fires, whose smoke does not per- 
fectly escape for want of sufficient draught, and it will be very ap- 
parent why it is that modern houses often comprise conditions eminently 
calculated to ensure the presence of this cause of disease. In public 
offices, schools, hospitals, churches, chapels, theatres, and other places 
where great numbers collect together, the mischief is still more fully 
in operation ; and it is quite certain that not only is the public health 
much injured in this way, but that much of the useful or agreeable ob- 
jects of such assemblies is also lost in consequence of the discomfort 
caused. 

The ill effects of deficient ventilation are increased by heat and mois- 
ture ; the former operates, not only by increasing the animal exhalations, 
but also by rarefying the air, and thus reducing the amount of oxygen 
in any given bulk ; moisture probably acts by lessening the difference be- 
tween the air respired, and that contained in the lungs, which promotes 
that diffusion, or interpenetration of gases whereby the access of oxygen 
to the air cells is ensured. For be it remembered, the air taken in at 
each inspiration, is not enough to reach far in the pulmonary tubes ; 
its further transfer into the air-cells is mainly accomplished by the law 
of diffusion of gases, which operates powerfully in proportion to the 
dissimilarity between the gases. 

Gases or vapours of a positively noxious quality are engendered, 
during certain occupations, which augment the evils of deficient venti- 
lation. Such is the case in many chemical works, slaughter-houses, 
and dissecting-rooms, soap, glue, and catgut manufactories, and in em- 
ployments in which materials are used containing mercury, white lead, 
and arsenic (§ 53.) The deleterious operation of effluvia arising under 
these circumstances may stop short of a directly poisonous effect, and 
yet by adding to the unwholesomeness of the atmosphere, it may gra- 
dually undermine the health: it is best counteracted by more efficient 
ventilation. 

73. (c) Defective drainage necessarily produces an active state of 



DEFECTIVE DRAINAGE. 



75 



the influences above specified, namely, filth and foul air; but it also 
implies circumstances that may exceed these in pernicious operation. 
The soil, which drains from habitations, contains in addition to excre- 
ment, dirty water, the washings and remnants of animal and vegetable 
matters used as food, and other offal; all these are mixed together and 
stagnant in the corrupting slough that is retained in cesspools and 
privies, or that is carried into sewers. The stench which exhales when 
these receptacles are opened, gives some idea of the deleterious influence 
they originate, and the fearfully poisonous nature of the emitted gases 
is often proved by the sudden faintness and sickness, nausea, vomiting, 
and diarrhoea, which attack persons engaged in emptying them. In- 
stances have occurred of individuals being speedily asphyxiated by the 
gases of cesspools ; and others are on record in which, although the re- 
sult was not immediately fatal, congestive or typhoid pneumonia en- 
sued, which passed into gangrene in the first stage. (Chomel.) The 
precise nature of the gases evolved in these circumstances has not been 
fully ascertained ; but they obviously contain much sulphuretted and 
carburetted hydrogen ; these, however, although known to be highly 
noxious, do not comprise the most dangerous ingredients of these of- 
fensive effluvia. It is no wonder then, that every ill-drained house has 
a Pandora's box, ready to pour forth its evils whenever occasion offers ; 
and always oozing them out in degrees sufficient for the impairment 
of the health of the inhabitants, and the gradual excitement of cachec- 
tic and other chronic diseases. Hence it is, as appears in the several 
sanitary reports before cited, that the mortality rises in a remarkable 
proportion in all those districts of towns where sewerage is absent or 
inefficient. The worst nuisance of this description is the cesspool with- 
out a drain from it ; unemptied for months or years, and often imper- 
fectly covered, it continually poisons both air and water; and typhoid 
fever, diarrhoea, cholera, dysentery, dyspepsia, inappetency, general 
weakness, and malnutrition are the results of its pestiferous operation 
acting in different degrees. Scarcely less injurious, and even more in- 
sidious in its operation, because the effluvium is less offensive, is the 
untrapped drain often found in connexion with the sewers of large 
towns. This cause of disease exists extensively in London, not only 
in the street drains, which are always open and emitting the gases of 
the sewer, the bad odour of which is perceptible during certain winds, 
but also in the drains of houses which are either intentionally or neg- 
ligently left open, or are not kept air-tight by the presence of water 
in the traps. Nothing is more common than to perceive the peculiar 
smell of the drain on entering a house, and in many instances I have 
found that this has proceeded from the trap being left open, or from 
the water being dried away, the trap being therefore inoperative, al- 
though requiring only the simplest expedient to remedy the evil. When 
a single trap is open in a house, especially in the winter when doors 
and windows are closed, and the supply of fresh air is inadequate for 
the fires in the house, the foul air is drawn up from the sewer in a 
strong current, and quickly pervades the house from bottom to top, 
carrying everywhere its pernicious influence. It its surprising how 
ignorant servants and their employers, and even professional men, seem 



76 



EXCITING CAUSES OE DISEASE. 



to be on this point, although one which so immediately concerns their 
health and comfort: I have visited in many houses where illness, or 
impeded convalescence, low nervous fevers, bowel complaints, influenza, 
neuralgia, and headaches, besides other ailments, have been induced 
by this cause. In some instances the leakage is a consequence of the 
inroads of rats, or the displacement of the brickwork of the drains. 
It may be useful to state, that besides by the smell, which is not ob- 
vious to every one, the effluvia of drains may be detected by the 
darkening of white paint, and the speedy spoiling of meat kept in 
the basement story of the house. 

74. (9.) Of all the exciting causes of disease, there are none more 
common than extremes or sudden transitions of temperature. Both 
heat and cold, however, operate on the living body in different modes, 
and cause disease in a variety of ways. 

Extreme heat and extreme cold are directly destructive to life. 
Heat above 180° coagulates the albumen of the blood, and thus ob- 
structs the blood-vessels, and produces other chemical changes of a dis- 
organizing nature (§ 53:) a part that has been raised to this tempera- 
ture, therefore, necessarily dies ; it cannot live again. It is true that 
we occasionally see the application of boiling water at 212°, of boiling 
oil at 600°, and of red hot iron at 1000°, produce no other effect than 
violent inflammation and blistering of a part ; but that is because these 
bodies have then been applied for too short a time to do more than 
violently stimulate the part ; time enough is not afforded to raise the 
part to the decomposing temperature; an instant more, and the part 
would be killed. 

Cold below 32° freezes the water of the fluids; and as it destroys 
the life of tender plants, so also it often kills parts of animals ; but 
whether by the expansion of the ice injuring the delicate organization, 
(Sir B. Brodie,) or whether from the mere stoppage of the circulation, 
or from some other cause, is unknown. The destroyed part may be 
afterwards separated from the living parts by the processes of inflam- 
mation and sloughing. From the observations of Dr. James Arnott, 
it appears, however, that parts of the surface and of limbs may be con- 
gealed by the application of a freezing mixture, without any permanent 
injury to the structure ; and he strongly recommends this method of 
benumbing the part to prevent the pain of surgical operations, as safer 
than the induction of general insensibility by the inhalation of chloro- 
form. Probably the duration and degree of this artificial congelation 
fall short of the more serious effects of frost bite. The method deserves 
a fuller trial not only for surgical purposes, but also for the sake of its 
therapeutical influence in the removal of pain and the subduction of 
inflammation. The power of the body to resist cold, whether generally 
or locally applied, is apparently connected with the strength of the 
circulation. When this is vigorous or under the influence of excite- 
ment, there may be little or no general chill, and the parts exposed to 
cold may not suffer even in intense degree of cold. On the other hand, 
where the circulation is weak and the vital powers low, a moderate de- 
gree of cold may take serious effect. In many instances the sick and 



EFFECTS OF HEAT AND COLD. 



77 



worn-out soldiers in the Crimea, suffered loss of limbs from frost-bite 
from two hours' exposure to a cold little below the freezing-point. 

75. A disorganizing degree of heat, if extensively applied, as in 
severe burns and scalds, acts like a violent mechanical injury — such 
as tearing off or crushing a limb (§ 52.) It directly depresses all the 
functions : the pulse becomes very weak, frequent, and sometimes irre- 
gular ; the muscular strength is almost annihilated, and consciousness 
is nearly or quite suspended. In this state, notwithstanding the sti- 
mulant power of heat, and the inflammation which it generally excites, 
patients require stimulants, and they often die in a state of complete 
collapse, without any rallying or reaction. Extreme cold, also, if ap- 
plied for some time to the whole body, depresses and paralyzes all its 
powers, even that of generating heat, and, therefore, of resisting cold. 
Sir Astley Cooper observed, that on plunging kittens into ice-cold water, 
the arterial blood did not become venous in the veins; and Chossat 
found, that when animals were killed by cold, there was arterial blood 
in the left cavities of the heart. The limbs become benumbed by ex- 
treme or continued cold: and hence persons are drowned in cold 
weather much more speedily than in warm. In degrees of cold, on the 
other hand, not sufficiently intense to destroy the vital processes, more 
oxygen is absorbed by the blood, more carbonic acid formed, and more 
heat generated, these being the means whereby animals are enabled to 
resist cold. As, however, extreme degrees of cold reduce the vital 
properties and functions of the body, so it is reasonable to infer that 
the prolonged application of more moderate cold must also impair them ; 
and this inference is confirmed by the fact that when the body is be- 
numbed by continued cold, the circulation is enfeebled, and the secre- 
tions more or less disturbed. 

76. Heat, in insufficient intensity to effect the decomposition of or- 
ganized structure, is directly stimulant. It excites the functions of 
organs, and when generally applied, may even induce a state of fever. 
Thus when a person is in a vapour bath, or a hot-air bath, the pulse 
is quickened, and the whole surface becomes red, full, and hot ; there 
are throbbing and pain in the temples, and a feeling of feverish op- 
pression, until a sweat breaks out ; this then soon relieves the superficial 
tension and fulness, and reduces the increased heat. Effects of this 
kind often ensue from confinement in overheated rooms : and if there 
be any tendency to local congestion or inflammation, particularly in 
the head, the excitement may be enough for the production of mischief. 
The continued operation of heat enervates, reduces the strength and 
appetite, and may excite disorder of the liver. Liebig thinks that the 
oppressed breathing, so often felt in heated rooms, may be ascribed to 
the smaller amount of oxygen which air rarefied by heat contains ; but 
it is probable that this is not the only cause. 

The exposure of a portion of the body to heat, may produce still 
more disordering effects, if the part overheated be of a nature disposing 
it to suffer from the excitement. Thus solar or artificial heat, applied 
to the head, may cause severe headache, apoplexy, or inflammation of 
the brain. Heat to the spine, as from sitting with the back near a 
large fire, is very apt to cause sickness and faintness, and, if continued, 



78 



EXCITING CAUSES OP DISEASE. 



may induce convulsions. More local inflammations, as of the eye, ear, 
and portions of the skin, are frequently caused by exposure of the suf- 
fering parts to heat. Gout may sometimes be excited in the feet by 
the application of the same stimulus ; this is often done with the design 
of localizing the disorder. 

77. Cold, on the other hand, is directly sedative. It contracts tis- 
sues and vessels, especially the arteries, and thus at first renders parts 
pale and shrunk. In persons of feeble circulation, the fingers are 
sometimes quite bloodless and numb after bathing; the cold having 
quite closed up the arteries. 1 But cold also retards the passage of the 
blood through the capillaries ; the viscidity of the liquor sanguinis seems 
to be increased by it ; the corpuscles stick to the sides of the vessels, 
or move but slowly, and the part soon becomes purple or blue from con- 
gestion of blood. This purple colour is chiefly seen in parts much ex- 
posed, and where the blood habitually enters with freedom, as for 
instance the cheeks, ears, nose, and hands. There is also much in- 
ternal congestion from the intropulsive operation of the cold — that is, 
the external parts being constricted and obstructed, blood accumulates 
more in internal parts, and the heart's force is mainly expended on 
these. This may in part account for the degree of stupor and ultimate 
insensibility into which persons exposed to extreme cold are apt to fall. 
In some such cases there has been a flow of blood from the nostrils or 
ears : the stupor has continued for hours after the heat and circulation 
have been restored ; and in fatal cases, much serous effusion has been 
found in the brain. 2 Further observation is needed on these points; 
but it is most probable that these changes are not the mere result of 
the congestive influence of cold. In proportion as the blood remains 
long stagnant other functions are also interrupted, nutrition and se- 
cretion in particular; and the arrest of these causes a more serious re- 
sult than what would follow from the mere occurrence of a temporary 
congestion. We shall hereafter find reason to conclude that the lower- 
ing of the chemical changes in the blood and tissues from the operation 
of cold, in itself contributes to increase the capillary congestion. 

78. Hitherto we have considered the immediate operation of cold 
(§ 74, 77.) But its indirect effects are more commonly known: these 
are, reaction, irritation, inflammation, and their consequences; they 
are more manifest where the cold has been partially applied, and the 
strength of the general circulation is not reduced. Thus, after a part 
has been exposed to severe cold, it becomes the seat of increased flow 
of blood, so soon as it is restored to warmth, this causes redness, pain, 
and more heat ; and various forms of inflammation may ensue, generally, 
however, modified by the specific effect which the previous cold has ex- 

1 A similar effect may be watched through the microscope, on applying ice-cold water 
to the frog's web: the arteries contract to obliteration. This is contrary to the asser- 
tion of Poiseuille. (See my Gulstonian Lectures, Med. Gaz., July 16, 1841, p. 639.) It 
must be remarked, that the primary action of cold on the arteries is strictly stimulant, 
exciting their vital property of contraction; but its direct operation on textures and or- 
gans is sedative, because it impedes the circulation which supports their functions. So, 
too, it has been found, that when its influence reaches the heart, it paralyzes its powers 

2 Kellie, Edinburgh Med. Journal, vol. i., p. 304. 



MORBIFIC OPERATION OF COLD. 



79 



ercised on the vessels and nerves ; and also varying with the strength 
of the general circulation. Thus, chilblain, gangrenous or erysipela- 
tous inflammation, paralysis, and altered sensation are among the in- 
direct effects of cold. As much of the disorder arises in these cases 
from the violence of the reaction and inflammation, and as this depends 
on the sudden return of heat and circulation in the part, it becomes an 
obvious measure of prudence in the treatment of frost-bitten limbs, to 
retard such return by cold applications. But as Dr. Alison well re- 
marks, this precaution is not needed, where the sedative effects of cold 
have been more general; here warmth and stimulants may be used 
freely, for there is no fear of an injurious partial reaction. 

79. We have hitherto been considering the manner in which cold 
causes disorder in the parts to which it is applied ; but this is not the 
most general way in which cold excites disease. A person gets his 
feet wet, stands in a draught of cold air, or, is exposed to cold when 
insufficiently clothed ; he afterwards becomes diseased — not in the feet, 
or the parts chilled, but in some internal part. He gets a sore throat, 
a "cold in the head" or chest, an inflammation of the lungs, a rheu- 
matism in the limbs, a looseness of the bowels, a catarrh of the bladder, 
or any other disease to which he may be predisposed (§ 14.) Now how 
does the external application of cold cause this internal disease? How 
is the effect transferred from external to internal parts? 

Dr. Alison supposes that the cold operates chiefly on the nerves, and 
that the sensation which it excites is conveyed by the nerves to the in- 
ternal organs, where its morbid effects become manifest. But it must 
be objected to this that the morbific effects of cold are by no means 
proportioned to the sensation, or nervous impression, which it excites. 
A person may have his limbs aching and benumbed with general cold ; 
and yet no internal disease results. But if he has been exerting him- 
self, is perspiring, and then gets his feet wet, or is otherwise chilled, 
and does not continue his exercise, he will be pretty sure to catch cold, 
and to exhibit some one or other of its internal morbid effects, even 
although he has scarcely been sensible of any impression. It therefore 
seems more probable, that external cold excites internal disease, by 
deranging the circulation and condition of the blood, particularly in 
the capillaries. Cold checks the secretion of the external surface, per- 
spiration ; it constricts and obstructs the vessels of the skin (§ 77,) and 
thus throws more blood inwardly, so that internal congestions are pro- 
duced — these internal congestions impair the functions of the affected 
organs, especially if they are such as are concerned in excretion (§ 68,) 
and in other ways lay the foundation of disease. This intropulsive 
effect of cold takes place more readily and to a greater extent, in pro- 
portion to the weakness or sluggishness of the capillary circulation. If 
this be weak naturally (§ 20,) there is a constant liability to " take 
cold." Or if it be weak and relaxed from previous excitement, during 
fatigue (§ 23, 24,) or during sleep, the same result is apt to follow. 
Hence persons are most liable to catch cold after being in a hot room, 
after making exertion, or when asleep. On the other hand, the inju- 
rious effect of cold is lessened, or prevented, by a vigorous state of the 
capillary circulation, whether that vigour be natural, or artificially ex- 



80 



EXCITING CAUSES OF DISEASE. 



cited by continued exertion, stimulating drinks, or by febrile excite- 
ment (§ 17.) 

On this view we can understand why the partial, but continued, ap- 
plication of cold, such as occurs from draughts of cold air, wearing 
damp clothes, and standing on cold stones, should be particularly inju- 
rious, even although the sensation of cold excited is not great. Such 
chilling influences acting long on the same part, completely constrict 
its vessels, check its secretion and nutrition, injure the balance of the 
circulation, and by determining a corresponding amount of congestion 
inwardly, fix it in some part predisposed to disease (§ 14.) Nor is it to 
be overlooked that this derangement of circulation and of secretion and 
nutrition produces a corresponding change in the condition of the blood ; 
and this change serves to explain why the morbific influence of cold 
often cannot be removed until some critical discharge takes place, as 
by perspiration or urine. It is probably by interrupting or modifying 
the processes of nutrition and disintegration of textures that cold ope- 
rates in causing rheumatic pains in muscles and fasciae exposed to its 
influence. Thus the decaying material which under ordinary warmth 
assumes the form of urea, may by the retarding influence of cold be 
changed only into lithic or lactic acid, and immediately exert that 
irritating influence on the part which causes the rheumatic pain result- 
ing directly from cold. 

When a person has thus taken cold, which he knows by general 
sensations of coldness and weak circulation, rather than by any feel- 
ings in the part chilled, powerful measures which tend to restore the 
balance of the circulation and excite the defective secretion, such as 
violent exertion, a hot or vapour bath, or stimulant drinks, will often 
prevent the further progress of disease. The general exposure to a 
cold atmosphere, if not long continued, is less injurious than a partial 
application, both because it disturbs the balance of the circulation less, 
and because also it supplies the lungs with denser air, and therefore 
with more oxygen ; its impression on the nerves of the face and chest 
also excites more energetic respiratory movements, which maintain the 
heat and the vigour of the circulation. Healthy persons rarely take 
cold when travelling on the top of a coach, or in a perfectly open car- 
riage, but they frequently suffer if in a close carriage with the windows 
open. 

Eailway travelling is particularly dangerous in cold weather, on ac- 
count of the strong current of air caused by the speed. It was not 
discovered, until abundantly illustrated by numberless cases of catarrh, 
lumbago, and pleurisy, that more clothing is required even in first-class 
railway carriages, than in stage coaches, and that there is rarely any 
need of an open window to secure ventilation. 

Damp foggy air seems to act injuriously on the body in a peculiar 
manner, independently of its mere temperature, irritating in particu- 
lar the eyes and air passages. Professor Schoenbein considers this 
effect to be due to the presence of ozone, a principle which he con- 
ceives to have the power of producing influenza and catarrh, at the 
same time that it is capable of destroying malarious and infectious 
poisons. 



RESISTANCE TO COLD. 81 

80. Susceptibility to the morbid effects of cold is to be diminished 
by means tending to invigorate the capillary circulation, especially 
when they are such at the same time as serve to promote that process 
of reaction which is nature's ordinary method of resisting cold. Now 
nothing does this more than sudden artificial applications of cold, as 
by cold bathing or sponging, followed by friction, exercise, heat, or 
stimulant applications, which promote the reaction (§ 16.) The great 
art in accomplishing these intentions, consists in using the cold in such 
a manner and degree, and in having the body in such a state before 
and after the application, that the reaction or glow shall be most fully 
produced. If the cold be applied too long, or when the body is ex- 
hausted by fatigue or exertion, or when it is naturally too weak, the 
depressing effects of the agent will be continued, there will be little or 
no reaction, and sensations of languor and chilliness will show that the 
application has been injurious instead of beneficial. The addition of 
salt to the water of baths communicates a stimulant property, which 
promotes reaction, and a similar influence results from the force or 
shock with which the water is applied. The shock excites frequent 
deep and forcible respirations through the influence of the nerves ; 
and these accelerated breathings are probably the efficient cause of the 
process of reaction which follows. 

The reaction which follows the judicious use of cold as a therapeutic 
agent, may prove serviceable, not only in resisting the further influ- 
ence of cold, but also by removing congestions and irregularities in the 
circulation produced by other causes, and by exciting in the capillaries 
and secernents new actions, which may supersede those of disease. It 
is thus that the "water cure" of Priessnitz chiefly operates; and 
although too powerful an agent to be intrusted to unskilled and un- 
scientific hands, it promises to become a valuable addition to the 
means of combating diseases, particularly of a chronic kind. The ex- 
citement and exhilaration sometimes produced by the free application 
and imbibition of cold water is very remarkable, and in numerous dis- 
orders connected with mere loss of tone in the vascular system, may 
prove very beneficial. But in cases of organic disease, or extreme 
weakness, the influence of cold water may be very injurious, even 
though it may seem refreshing and invigorating for the time. I have 
known many cases in which patients have fancied themselves im- 
proving under the treatment, when in fact organic mischief has been 
rapidly increasing, and flesh and blood have been wasting. The ex- 
citement induced by the water almost resembles intoxication, giving a 
fictitious feeling of strength, in the midst of increasing weakness. 

81. In the preceding remarks on cold, it must be understood that 
the term is applied relatively, not absolutely : cold is not a fixed tem- 
perature, or range of temperature; but simply a degree of heat con- 
siderably below the temperature of the body. Thus a living body that 
has been warmed throughout to a heat of 98°, and kept in an excited 
state by that temperature, would suffer from a draught of air at 70°, 
which would then feel cold to the body, and produce the physiological 
and pathological effects of cold. But if the body had not been pre- 
viously warmed, so that the temperature of most parts of the surface 

6 



82 



EXCITING CAUSES OF DISEASE. 



exceeded 85°, or if, being so warmed, the energies of the body had 
not been exhausted, then air at 70° would feel pleasant, and produce 
no chill. This is one of many conditions which distinguish vital from 
physical properties. Physical or chemical properties are invariably 
affected in a certain way by given temperatures, independent of pre- 
vious circumstances : but vital properties are variously affected by them 
in consequence of possessing that power of adaptation, whereby they 
are enabled to maintain the same states of function in varying external 
circumstances. 

It is for these reasons that atmospheric changes in variable climates 
are fertile causes of disease. In this country on a sudden change of 
wind, the temperature often falls 15° or 20° in the course of a day, 
and without any particular exposure the body may become so chilled 
in consequence as to suffer to a degree sufficient for the production of 
disease. Internal congestions commonly result, but the seat of the 
congestion varies with the state of predisposition. After the heat of 
summer, the organs most apt to suffer are the liver and the abdominal 
viscera, because they have then been exposed to great excitement (§ 25 :) 
on the other hand, in the spring, after the winter cold, the lungs and 
air-passages are more prone to derangement (§ 26.) 

II. NON-COGNIZABLE AGENTS. 

We now proceed to notice those causes of disease, whose existence 
is merely inferred from the fact that disease prevails under certain 
circumstances, and cannot be explained unless upon the assumption of 
the existence of certain peculiar agencies, although we cannot prove 
their existence in any other way (§ 51.) These comprise what are 
termed the endemic, epidemic, and infectious poisons. In the reports 
of the Registrar General these poisons are termed zymotic (£1^, a fer- 
ment:) the epithet implies an hypothetical explanation, which may 
perhaps be still deemed open to question ; but it is, nevertheless, a very 
convenient designation for these mysterious morbific influences. 

(1.) ENDEMIC POISONS. 

82. Persons living in a marshy district are frequently afflicted by a 
disease called ague, which does not attack people inhabiting dry lands. 
And again, the inhabitants of certain deep valleys are often affected 
with the swelling in the neck, called bronchocele or goitre ; while the 
neighbouring mountaineers are not so affected ; and when the inhabi- 
tants of the valleys remove their residence to the mountains, they 
generally lose their liability to the disease. These affections are in- 
stances of diseases which may be said to dwell among the residents in 
particular spots ; hence they are called endemic, in the people (sv %*o ? .) 

Much doubt still exists regarding the precise source of endemic in- 
fluence ; some persons suppose that it is to be traced to the water, others 
to emanations from the soil. Intermittent and remittent fevers cer- 
tainly very commonly originate in marshes, jungles, and rice-grounds, 
for it has been found that when the wind blows across such tracts of 
land, the disease appears in persons residing to leeward, but not in 



ENDEMIC POISONS. 



83 



those residing to windward; and it has been abundantly proved, that 
when the marshy spots are drained, ague ceases. From these and 
similar facts, it has been inferred that the cause of ague is an efflu- 
vium, miasm, malaria, or bad air; an aerial poison, inhaled with the 
breath, and absorbed from the lungs into the system. 

83. The exact nature of marsh malaria has not hitherto been deter- 
mined. It has never been detected by chemical analysis. Professor 
Daniel conjectured that the malaria which causes the destructive en- 
demic fevers on the coast of Western Africa, might be sulphuretted 
hydrogen evolved from the sea water by the decomposing vegetable mat- 
ter brought down by the rivers ; but experiments made in the late un- 
fortunate expedition to the Niger are opposed to this notion. The mi- 
croscope, rather than chemical analysis, will probably one day throw 
light on the nature of malaria. 

But although the exact nature of marsh malaria is not known, we 
are acquainted with some of its general properties. It seems to be 
heavier than air ; for persons occupying a ground floor suffer from it 
more than those living in upper apartments. Water seems to absorb 
or destroy it ; for persons on board ship, or on the side of a lake op- 
posite to the marsh, are not affected ; although a favourable wind will 
convey the pernicious influence to a much greater distance over land. 
A damp state of the air, however, favours its production: good fires 
in a house afford marked protection to its inmates. It seems to be 
attracted by trees ; for the vicinity of trees is doubly dangerous ; whilst 
places beyond the trees are more free from its effects than others at 
the same distance which are unsheltered. 

84. The chief points known, with regard to the source of malaria, 
are, that it arises from the operation of the sun's heat on marshy 
ground, or on the banks or deltas of rivers, especially if devoid of 
tidal flow, after evaporation has proceeded to some extent ; putrefac- 
tion of organic matter not being an essential part of the process. 1 The 
virulence of the malaria, shown in the severity of the disease excited, 
and in the number of persons who are affected, seems to bear some 
proportion to the heat, which has led to its development. Thus the 
ague of this country, the pernicious intermittent of Italy, and the ma- 
lignant intermittent of Western Africa and the West Indies, all seem 
to arise from similar endemic causes, but differ materially in their viru- 
lence, being the most formidable where the heat is greatest. A cer- 
tain amount of moisture is, however, requisite to the effect; a very dry 
season, which desiccates a marsh, stops the malaria ; and the deposit 
of the evening dew always favours its production (§ 83.) Excess of 
moisture, on the other hand, checks its development, so that a very 
wet season, as well as a very dry one, may render a marsh less un- 
healthy (§ 83.) But extreme heat does not diminish malaria on the 
banks of rivers, because portions of these are never dry. The low 
shores of the Mediterranean and the Black Sea are always malarious 
at the commencement of hot weather, because in the absence of a tide 

1 Chisholm and Ferguson, Ed. Med. and Surg. Journal, vol. Trans. Roy. Soc. 
Edin., -vol. ix. 



84 



EXCITING CAUSES OF DISEASE. 



there is none of that frequent salt washing and drainage, which puri- 
fies other European shores. 

It is not only marshy, or low grounds, that engender malaria, al- 
though these are the situations that are most favourable to its produc- 
tion. All that seems to be realty requisite, is the.continued operation 
of the sun's heat on moisture stagnant upon, or near, the surface of 
the ground. I know instances in which ague has attacked persons 
living on a height of mountain limestone, forming a small table land 
below higher ground. Some swampy lands are not malarious ; peat 
bogs, in particular, show a remarkable exemption from decomposition 
and effluvia of all kinds. 

It is a curious fact that malaria seems to be more active at night, 
than by day. Its power seems to be diminished by the cultivation and 
dense peopling of districts where it has prevailed. The Italians date 
its development in the deadly Maremma from the time that the coun- 
try was desolated by the Plague. This influence of the population is 
probably connected more with their activity than with their presence ; 
for the ague disappears in proportion as the inhabitants drain the 
marshes and remove the source of the poison. 

85. The morbid effects of marsh miasms are multiform: intermittent 
and remittent fevers of various types, are the most remarkable among 
these, and particularly affect the new residents in a marshy spot ; but 
the older inhabitants suffer from diseases of the liver and spleen, ner- 
vous affections, rheumatism, dropsy, and cachectic complaints, and are 
generally short-lived. The first operation of the malarious poison 
seems to be on the quality and distribution of the blood: in the worst 
cases this liquid becomes speedily darker in colour, and otherwise al- 
tered, and accumulates to an extraordinary amount in the internal or- 
gans, where it then suffers still further in consequence of its stagna- 
tion and want of purification by the ordinary processes of excretion. 
The fit of an ague is the reaction (§ 16) of the vital powers against this 
cumulative influence of the poison on the blood : if the vital powers are 
strong, and the dose of the poison not overwhelming, the fit success- 
fully removes the internal congestions, and partially restores the purity 
of the blood through increased excretion ; but some poison being still 
in the system, similar effects are again produced after a longer or. 
shorter interval ; and so alternate attacks of ague, and intermissions, 
appear in succession. 

One of the most remarkable characters in the diseases resulting 
from malaria, is the periodicity of their attacks, and the diminution or 
cessation of the symptoms in the interval. This is probably due to 
the alternate accumulation of the malarious influence in the body and 
the reaction of the vital powers against it. 

86. There can be little doubt that there are other kinds of malaria 
besides those which cause intermittent and remittent fever (§ 80, 81.) 
Yellow fever and plague are endemic diseases, most probably arising 
from aerial poisons. The propagation and severity of the latter, and 
perhaps even its very existence, is to be mainly ascribed to the filth 
and impurities of the towns where it prevails. These, however, are 



EPIDEMIC POISONS. 



85 



cognizable causes, "whose operation in exciting and predisposing to dis- 
ease, has been already noticed (§ 70 — 73, § 22.) 

Bronchocele and cretinism, and allied results of depraved nutrition, 
manifested in glandular enlargements, fibrinous and dropsical swellings 
of the cellular tissue, distorted limbs, stunted growth of the body, and 
imperfect development of the mind, are dependent on endemic causes ; 
which are most probably miasms arising from the low marshy grounds 
of the deep valleys of Savoy. 

Some other endemic diseases can also be traced to cognizable causes ; 
the Guinea worm, seems to be due to drinking water containing its 
ova; the pellagra of Northern Italy, and the plica of Poland, are 
brought about by neglect of cleanliness, and unhealthy modes of living, 
and probably are both immediately dependent on the production and 
propagation of a parasitic vegetable on the roots of the hair and skin. 1 

(2.) EPIDEMIC POISONS. 

87. There is another group of diseases, which resemble the endemic 
in affecting many persons in the same place and at the same time (§ 81.) 
But they differ in these respects, they do not regularly return at stated 
seasons (§ 84,) and they are not confined to particular localities (§ 82,) 
although they infest some more than others ; they attack a whole dis- 
trict, a whole country— and sometimes almost a whole hemisphere — 
within a very short time ; often coming on without obvious cause ; pre- 
vailing for awhile, and then disappearing for an uncertain period ; 
which may be for months, or years, or even for intervals too long to 
be remembered. These disorders are called epidemics, (axi o-^ 0 ?,) be- 
cause they seem like a blight, or pernicious influence, blowing on the 
people; and therefore affecting a whole country at once. 

88. The cause of these diseases is supposed to be something in the 
atmosphere ; for the atmosphere is the only thing that is common to 
all the places to which the affection extends : but the nature of the 
epidemic poison is just as mysterious as the endemic. It is true that 
some diseases, which seem to prevail epidemically, may be traced to 
the cognizable qualities, cold, heat, dryness, and moisture of the air 
(§ 74, et seq.) Thus diseases excited by cold sometimes prevail, as 
epidemics, in the winter ; those excited by heat, in the summer ; catarrhs 
and rheumatisms abound in cold damp weather; croup and quinsy be- 
come common during the prevalence of a cold east wind in the spring ; 
diarrhoea and dysentery are rife in the autumnal fruit season. Other 
disorders, again, such as dysenteries, fevers, and scurvies, have in some 
instances obviously arisen from deficient or contaminated food, bad 
water, or some other distinctly cognizable cause (§ 60, 70, et seq.) 
But as these causes all belong to the class of cognizable agents already 
noticed (§ 52, et seq.,) they do not need to be adverted to here. 

89. But there are diseases occurring epidemically which do not ap- 
pear to have any discoverable connexion with season or temperature. 
Thus an epidemic influenza may come on at any season of the year, 
and rapidly spread through a country, and then cease as unaccountably 



1 Robin, Histoire Naturelle des Vegetaux Parasites. 1853. 



8G 



EXCITING CAUSES OF DISEASE. 



as it began, or it may break out simultaneously at distant parts where 
the temperatnre is exceedingly different. 1 So, too, diseases that are 
obviously excited by other causes, whether infectious or otherwise — 
as, for instance, typhus and scarlet fevers, measles, small-pox, and 
erysipelas, — sometimes prevail so extensively, and with such peculiar 
characters, that some common influence besides the agencies that usually 
produce them, must be admitted to be concerned in their sudden ap- 
pearance and diffusion. The nature of this influence is unknown; but 
it is spoken of as epidemic (§ 87.) 

90. Various diseases, fevers, inflammations, and many other kinds 
of ailments, at some periods assume a remarkable character in common, 
or type (as it is called ;) for example, they may be attended with unusual 
weakness, or unusual excitement, or a tendency to hemorrhage. This is 
said to be due to an epidemic or 'prevailing diathesis, or constitution. Thus 
at uncertain times, fevers, wherever arising, and from whatever source, 
are always more low, typhoid, or adynamic, than usual ; exanthema- 
tous diseases then generally partake of the same character ; and even 
patients affected with inflammations will not bear depletion as they 
would at other times. Of late years this low type has prevailed more 
or less, and may be contrasted with that of a period of thirty years ago, 
when an inflammatory diathesis was as common, and blood-letting was 
then advantageously employed even in continued fever. 

91. It has been before stated (§ 88,) that we are quite in the dark 
as to the nature of epidemic influences or causes of disease. Many 
conjectures have been advanced, some of them with much plausibility, 
although without any substantial support. Dr. Prout states that, 
shortly before and during the prevalence of the malignant cholera in 
this country, he noticed a slight but decided increase in the average 
weight of the atmosphere, as if from the addition of some ponderous gas. 
At the same time, he remarked an unusual acidity in the saliva even 
of healthy persons, and such an absence of lithic acid from the urine, 
that he was inclined to suppose the existence of a peculiar disposition 
to form oxalic acid, and to refer this to the same unknown cause which 
was active in the production of cholera (60.) He suggested the possi- 
bility that some such subtile deleterious agent, as seleniuretted hydro- 
gen, might be diffused through the atmosphere and produce the perni- 
cious results observed. Such an agent might be evolved from volcanoes, 
and" it is a curious fact that several severe epidemics have been known 
to be preceded by volcanic eruptions. This has not however been 
found to be alwa}'S, or even often, the case. Neither do volcanic 
countries suffer the first, or the most intensely from epidemics, as they 
ought to do, if this supposition were based on fact. Electro-magnetic 
influence, and abnormal production of ozone, are among the assumed 
causes of epidemic disorder, and the assumption has more of probability 
on its side, on account of the ubiquitous character of these agents. 
But here, again, there is no other evidence for the opinion to rest upon, 
than a few equivocal observations regarding the occurrence of auroras 

1 The influenza of 1836 prevailed simultaneously in London and Cape Town, although 
it was then the summer of one place and the winter of the other. See "Annals of In- 
fluenza," by Dr. Theophilus Thompson. 1850. 



INFECTIOUS POISONS. 



87 



boreales, and disagreeably odorous fogs (said to contain ozone,) coinci- 
dently with certain epidemic invasions. 

92. Many analogical arguments have been adduced in support of a 
favourite notion of Linnaeus, namely that epidemic diseases are caused 
by animalcule tribes. This hypothesis has been ably advocated by Sir 
Hi Holland, 1 Dr. Henle, 2 and others. Before I had seen the opinions 
of these authors, I had, in my lectures, stated some arguments which 
appear to favour this notion, and which will be noticed again when 
speaking of infection. It may here, however, be remarked, that the 
chief facts which afford a countenance to the view are the following: — 
1. Epidemic diseases resemble the effects of the blight insects, by ap- 
pearing and disappearing without evident cause, in uncertain places 
and at uncertain periods. 2. Unusual swarms of insects, and various 
epidemic visitations have been frequently remarked as occurring toge- 
ther, although it must be confessed that no uniformity has been found to 
obtain in either the characters of the insects, or the diseases. 3. Fresh 
proofs are continually coming under notice of the existence of parasitic 
animals and plants in living animals, often, too, unmistakeably present- 
ing themselves as causes of disease : this is seen in intestinal worms and 
other entozoa, the acari of itch, and the rot-worm of sheep. 3 4. The 
history and symptoms of such epidemic diseases, as cholera and influ- 
enza, are in no way inconsistent with the hypothesis that they are 
caused by the sudden development of animalcules from ova received 
into the blood. It must be finally stated, however, that there is an 
entire deficiency of all direct observations which could confer support 
on this hypothesis ; and, perhaps, it may also be objected to it, that 
the seasons in which epidemics sometimes appear, are not always those 
most favourable to the development of animalcule life. 4 

(3.) INFECTIOUS POISONS. 

93. The terms infection and contagion are applied to the production 
of a disease by the influence of a morbid matter proceeding from the 
body of a person who is, or has been, the subject of the disorder. They 

1 Medical Notes and Reflections, 1840, p. 597. 

2 Pathological Researches, British and Foreign Medical Review, April, 1840. 

3 Vegetable parasites, too, often appear in the same light, as instanced in the myco- 
derrnatous vegetations of porrigo, and pityriasis versicolor. (See Sprenger, Canstatt's 
Jahresbuch. 1851.) And in the parasitic algas of aphtha. (See Robin, Histoire Nat. 
des Vegetaux Parasites. 1853.) Gruby, Comptes Rendus, t. xlii. Bennett, Trans. 
Royal Soc. Edin., 1842. 

4 The prevalence of the south-east -wind has been observed to be particularly favour- 
able to the increase of both cholera and influenza; and I cannot but think that this has 
some connexion with the general tendency which the former shows to spread chiefly from 
east to west. Has the morbific power of this wind aught to do with the haziness of the 
air which commonly prevails with it? — a haziness perceptible in the country remote from 
smoke and quite distinct from fog? What is this haze ? In the west of England, a hazy 
day in spring is called a blight. Ehrenberg has discovered by the microscope that wind 
deposits a fine dust, even on mountain tops, which has almost an identity of character 
wherever found, and which contains in addition to various earthy and oxy-metallic 
matters, fragments of fossil shells and shields of extreme minuteness. Organic exuviae 
of this kind have been found on the coast of Africa, which seem to be the same with 
deposits lying near the summits of the Andes. Numerous facts seem to indicate that 
there are currents in the upper regions of the atmosphere that are equal to the task of 
transmitting subtle organic materials from one hemisphere to the other. 



88 



EXCITING CAUSES OF DISEASE. 



imply, in short, disease produced by communication. The proofs that 
disease is sometimes thus propagated from one individual to another 
are, first, the general one, that those who have intercourse with the 
sick, are affected in much greater numbers than those who have not 
(§ 12;) and, secondly, the direct and individual act of infecting a 
healthy person with matter taken from a person in disease. This lat- 
ter plan, although available only in some forms of infectious disease, 
may nevertheless be considered as a sufficient proof of the general fact 
of contagion — that is, of the power of disease, under certain circum- 
stances, to propagate itself. 1 

94. I have just alluded (§ 93,) to there being different ways in which 
infection may operate; and may now specify three distinct modes in 
which it may do so : — 

(1.) Infection through wounds, or an abraded surface; this is what 
is commonly misnamed inoculation: it is instanced in hydrophobia, 
where the morbid matter is contained in the saliva, or guttural mucus 
of the rabid animal; and in cow-pox, where it is afforded by a specific 
vesicle. 

95. (2.) Infection by contact, different parts of the body being, how- 
ever, only susceptible of different diseases; this is contagion properly 
so thus called: thus the urethra and conjunctiva only suffer in gonor- 
rhoea, the vicinity of the external openings of the passages in syphilis, 
the skin in scabies, the scalp of the head in porrigo — in all these cases 
the morbid matter that effects the mischief issues generally from simi- 
lar parts. 

96. (3.) Infection by exhalations in the breath, or cutaneous or 
other secretion ; conveyed through the air to the mouth and air pas- 
sages: as instanced in the case of measles, scarlatina, hooping-cough, 
typhus, and other infectious fevers. 

97. Some diseases are capable of propagating themselves by several 
of these modes; small-pox, for instance, may be communicated by in- 
fection through punctures in the skin (§ 94 9 ) by application to the eye 
(true inoculation, § 95,) — and through the general mass of the respi- 
rable air (96:) probably inoculation might also be effected with other 
febrile poisons, if they could be procured in the same palpable form as 
the matter of small-pox. All this merely shows that the matter of in- 
fection can exist suspended in the air, as well as in a fluid or solid 
state; and that it may accordingly get access to the system by diffe- 
rent avenues as it is in the one or the other of these. It is pretty 
clear, too, that the poison of infection may sometimes be conveyed by 
articles of clothing, bedding, or household furniture. This is the case 
with scarlatina, small-pox, and perhaps the plague, but in these matters 
popular prejudice generally goes beyond the truth. 

98. Many of those who are skeptical regarding the reality of infec- 
tion, direct their objections only against aerial communication, and do 
not question the other modes. But the real difficulty of the case is, 
not that infectious matter may be diffused through the air — our sense 

1 Some facts, and able arguments, tending to establish the existence of contagion 
in cholera and other epidemics may be found in a paper entitled "The Exciting Causes 
of Epidemics," by Professor Alison, in the Brit, and For. Med. Chir. Rev., Jan., 1854. 



PROPERTIES OF INFECTION. 



89 



of smell informs us that animal effluvia are constantly so diffused — but 
that infection can take place by any mode ; that is, that disease should 
be able to propagate itself. There are only two parallel cases in na- 
ture, in which analogous actions take place. One is that of what is 
called septic matter, leaven, or ferment; a little of which being intro- 
duced into organic matter promotes changes and decompositions in it. — 
"A little leaven leaveneth the whole lump." This is supposed by Lie- 
big and other chemists, to be a chemical action ; operating in the manner 
of heat, by altering the molecular relations and affinities of compound 
principles; as, for example, when some such protein compound as glu- 
ten in a certain state of decomposition, promotes the conversion of 
starch into sugar, and of sugar into lactic acid, and then this into bu- 
tyric and carbonic acids. It has, on the other hand, been maintained 
by Turpin, Cagniard De la Tour and others, that fermentation is 
caused by the production and growth of living molecules of a vegetable 
nature (torulse,) which have the power to modify the affinities of the 
material in which they are developed, and that it spreads by the mul- 
tiplication of these living bodies. If this notion be based in truth, it 
transfers the explanation of leaven or ferment, into the next category 
(§ 99.) 

99. The other case analogous to the propagation of disease by infec- 
tion, is that of the vital power of generation; in this case, organized 
matter propagates itself in the animal and in the vegetable world. 
Does then the poison of contagion consist of animal ova, or vegetable 
seeds? Are infectious diseases results of the invasions and operations 
of living parasites disturbing in sundry ways the functions and struc- 
tures of the body, each after its own kind, until the vital powers either 
succumb before them or succeed in expelling the invaders from the 
system? (§ 16.) Such an opinion has been many times proposed, and 
is, in a degree, implied in the term incubation, (sitting on eggs to hatch 
them,) which is commonly applied to the period that intervenes be- 
tween the reception of the infection and the first appearance of the 
symptoms. The notion, indeed, receives support from the phenomena 
of itch, which certainly infects through an insect, the itch-mite, and 
spreads by this animal's propagation ; and from those of porrigo, or 
favus, which is now known to depend on a minute parasitic vegetable, 
and to infect through its seeds or sporules. 1 It may however be ob- 
jected, that these are instances of mere local disease, and by no means 
parallel with the case of infectious fevers, or syphilis, in which the whole 
system is affected. 

It might be expected that small-pox and cow-pox would throw some 
light on this difficult subject, because the infectious matter of those 
disorders is found in the incipient pustule ; but this has not hitherto 
proved to be the case. M. Gruby states that he has discovered a few 
animalcules in the lymph of the variolous vesicles, but its disease-pro- 
ducing power has not been traced to these creatures. 

100. There are certain general properties in all forms of infection 

1 Sclionlein, Muller's Archiv., 1839, p. 82. Gruby, Gazette Medicale, Juillet 17, 1841. 
Robin, Hist. Nat. des Vegetans Parasites. 1853. 



90 



EXCITING CAUSES OF DISEASE. 



which seem rather to favour the notion that they are dependent upon 
parasitic creatures, and which further deserve to be mentioned on ac- 
count of their practical importance. Infectious matter is destroyed 
by a temperature that is higher than 120° Fahr., and by strong che- 
mical agents, especially chlorine ; its activity is impaired by cold ; and 
in the case of aerial infection, is rendered harmless by intense cold 
and free ventilation. Hence many infectious diseases cease when hard 
frost sets in. On the other hand, warmth, closeness, and filth, increase 
the virulence of the mischief, and become, as it were, a nursery of 
pestilence. Xothing tends to promote the spread of an infectious dis- 
ease more than crowding .together many people who are suffering un- 
der it. Each one is then a separate source of contagion ; and as these 
sources are multiplied in an apartment, the contained air becomes more 
contaminated in proportion. This is the chief reason why medical at- 
tendants and nurses escape infection much more rarely in fever hos- 
pitals and wards, than they do in hospitals where the fever patients 
are widely distributed among persons suffering from other disorders. 

The greater number of infectious disorders, especially those which 
have the character in the most marked degree, leave the system more 
or less free from liability to their recurrence. This immunity, however, 
diminishes somewhat with lapse of years. A large proportion of those 
who have once had measles, small-pox, or hooping-cough, never take 
these disorders again, even although fully exposed to the infection. 
Some, however, do catch them again after the lapse of many years ; 
most of these exhibit a much milder type of the affection than is usual 
in a first attack. This comparative security against a repeated infec- 
tion is involved in much mystery, but it is attributed by Liebig, and 
others who favour the zymotic, or fermentation hypothesis, to the ex- 
haustion of a certain material which is the subject of the fermentative 
change, and which is considered to be not easily again reproduced. 
All this is, however, pure hypothesis, and unsustained by any trust- 
worthy facts. 

[The too frequently repeated visitations of epidemic cholera, have 
left behind them a few hints that may help to guide future investiga- 
tors in the right direction, when they seek to determine the nature of 
the concealed causes of epidemic and infectious diseases. There can 
be.no doubt that cholera is caused by some subtle poison which travels. 
Its path may be followed almost as if it left visible traces of its foot- 
steps. It is equally clear that it avails itself of material means of 
transport. Instances have occurred again and again, where the clothes 
in which cholera patients have died have communicated the disorder 
to healthy persons. But it is no less clear that this subtle agent re- 
quires a prepared recipient in order that it may become operative for 
evil. Comparatively few persons are susceptible to its action, even 
when it is rendered very intense by confinement in impure and badly 
ventilated apartments. Cholera, then, very aptly illustrates what has 
been already said regarding the necessity of predisposing and exciting 
influences conspiring for the production of disease. The human body 
is capable of being predisposed to become affected by cholera through 
the operation of various debilitating agents, but it does not even then 



DISTINCTIONS OF ZYMOTIC POISONS 



91 



contract the disease, unless it is exposed to action of the peculiar sub- 
tle poison that broods unseen in the air, and marches through its trans- 
parent spaces, bent on the errand of death. 

But there is this highly important and interesting peculiarity about 
the poison of cholera, — although it propagates itself, it is not able to 

i do so, unless a certain material is provided for it to feed upon at the 
time. It must have moisture and exhalations from decaying organic 
matters, or it cannot thrive, and reproduce itself. If these essential 

, supports are wanting, it makes no progress, and disappears. The 
cholera poison spreads centrifugally from any focal point in which it 
has been called into existence, as waves of water extend round a spot 
into which a stone has been dropped, growing weaker, however, as it 
spreads, and at last giving no appreciable token of its existence, un- 
less it crosses some locality in which the material elements of the poi- 
son are collected in a very concentrated state, some fated spot in which 
moisture and the products of decomposition dwell. Then the active 
poison is again called into existence out of these matters. A new focus 
of infectious influence is made, and from this the epidemic contagion 
again spreads centrifugally as from a new centre of departure. The 

; latent material of the cholera poison may be likened to the charcoal, 

! nitre and sulphur, that lie side by side in the grains of gunpowder. 
The explosive substance is there, but no explosion takes place until 

; the quickening spark comes. Then the consuming flame breaks out. 
Moisture and putrefactive effluvia are the rough material of cholera 
poison, but this material is never worked into its effective and finished 
state, unless under the presence of poison already complete and active. 
Hence it is that the cholera poison travels, but only through regions 
of moisture and filth; and hence, too, it is that the disorder grows 
milder as it spreads, but again breaks forth in certain spots with re- 
newed virulence from time to time. It is curious that either the zy- 
motic or the parasitic theory of infection may be supposed to receive 
support from these considerations. It may be deemed either that the 
infection finds new material that it can change into a morbific agent 
like itself by fermentation ; or on the other hand that the living para- 
sites alight upon deposits of food which they are able to assimilate and 
convert into an offspring like to themselves. So much for hypothesis. 
— Note by Dr. 31ann.~\ 

101. It may be useful again to point out the characteristic peculiari- 
ties of infectious, endemic and epidemic diseases ; for these peculiarities 
are so many proofs of the reality of infection viewed as an immediate 
cause of disease. 

Infectious diseases first attack individuals in some given locality, and 
then gradually spread in the vicinity, or in the direction in which there 
is most human intercourse. If care be taken, early and completely to 
separate the diseased from the healthy, the disease does not spread 
among the latter. 

102. Endemic diseases attack many individuals simultaneously in 
certain confined localities, (§ 81,) and do not spread beyond these 
localities ; separation of the sick from the healthy does not give the 
latter security; but removing the healthy to another spot does. 



92 



EXCITING CAUSES OF DISEASE. 



103. Epidemic diseases simultaneously attack many individuals over 
a wide extent of country (§ 88:) but do not increase particularly in the 
vicinity of those first affected, nor yet in proportion to intercourse with 
these, but rather in proportion to the prevalence of certain conditions 
that are of the nature of predisposing or determining causes (§ 19.) 

104. It must always be borne in mind that some diseases are sus- 
pected to originate and spread by more than one of these modes. This 
is probably the case with typhus fever, plague, cholera, and dysentery. 
It has been already mentioned that infectious diseases, like small-pox, 
scarlatina, and measles, are occasionally increased and modified by 
epidemic influences (§ 90, 91 ;) the same thing may also be stated of 
some endemic maladies. The unquestionable aggravation of contagious 
and epidemic complaints in consequence of endemic impurities, (§ 85,) 
makes it plain that all these several causes may operate conjointly. It 
is under such circumstances of aggravation, combined with strongly 
prevailing predispositions, induced by famine (§ 21,) fatigue (§ 23,) 
confinement (§ 22,) defective supply of air (§ 24, 72,) or mental depres- 
sion (§ 28,) that epidemics not only spread more rapidly, but also as- 
sume so intense a form, that they become very destructive, and so earn 
for themselves the right to be called malignant and pestilential. 

The direct operation of most of this class of morbific causes is de- 
pressing, so that where these influences are strongest, the resulting 
disease is the most sure to wear the character of adynamia, asthenia, 
or prostration of the vital powers. As they exhibit influences directly 
noxious to life, they are commonly designated specific poisons. But 
there is in the system the antagonist principle of vital resistance (§ 16,) 
which leads to various processes of reaction, exhibited in different de- 
grees, according to the relative strengths of the poison and of the re- 
sisting power, and often also according to the absence or presence of 
cognizable agents which act at the same time as predisposing, deter- 
mining, or co-operating causes. For instance, in warm weather the 
poisonous influences are generally strong (§ 84, 100,) and the bodily 
powers weak (§ 24 ;) the resulting disease is then consequently one of 
more complete adynamia. In moderately cold weather, on the other 
hand, the specific poison is less intense, and the system more ready to 
react, not only against it, but also against the cold which is operative 
with it ; this leads to a more inflammatory type in the consequent dis- 
ease (§ 79, 81.) 

The zymotic theory of epidemic, endemic, and infectious influences, 
affords a very reasonable explanation of the decomposition and putre- 
faction which they work in the blood, and subsequently in all the 
fluids and solids of the body. Dr. Carpenter points out 1 that there is 
one condition very likely to dispose the body to suffer from their inju- 
rious influence, namely, the presence in the system of an azotized 
matter tending to decomposition, whether arising from a rapid disinte- 
gration of materials of the body, as occurs after child-birth, accidental 
injuries, surgical operations, excessive fatigue, or extreme privation, — 
or caused by impaired action of the depurating organs of respiration 



1 Brit, and For. Med. Chir. Rev., Jan., 1853. 



ANTIDOTES TO ZYMOTIC POISONS. 



93 



and excretion, in consequence of close confinement in impure air, ex- 
haustion of vital power from intemperance and habitual excesses, — or 
directly introduced in the form of unwholesome food in a decaying 
state (§ 35.) 

105. The means that have been found most effectual in preventing 
the spread, and of counteracting the effects of zymotic poisons are 
chiefly of the nature of antiseptics, which may operate without as well 
as within the body, — and stimulants, tonics, and eliminants, whose in- 
fluence is limited to the living structure. Of the, numerous class of 
agents to which an antiseptic property is ascribed, there are two which 
especially deserve mention, as having been proved to be highly useful 
as disinfectants, or purifiers from the contaminating matters of infec- 
tion and malaria ; these are chlorine and charcoal. Chlorine seems 
capable of destroying all kinds of zymotic poison, and may be usefully 
employed to purify the air, walls and floors of infected houses ; and in 
a liquid state added to excreted matters, it removes their fetid effluvia. 
But its acrid qualities limit its use in inhabited rooms, and it can be 
applied only in a very diluted state as an internal or external remedy. 
Charcoal, recently prepared, is equally efficacious as a purifier, and 
its innocuous properties make it very eligible for use in a great variety 
of ways. Placed in shallow dishes in infected rooms, it speedily ab- 
sorbs from the air all offensive effluvia, and destroys all bad odours. 1 
Applied in a poultice to sloughing sores or ill-conditioned ulcers, it ac- 
celerates the decomposition and removal of the dead parts, whilst it 
removes their fcetor, and relieves much of the pain and irritation atten- 
dant on them. I have employed it with great advantage in an enema 
with opium and sulphate of copper in the worst forms of dysentery, in 
w T hich the putrid and bloody discharges speedily lead to fatal prostration ; 
it always relieved the dysenteric symptoms and corrected the fcetor of 
the discharges, and in two cases of the worst aspect the patients re- 
covered. How far the use of charcoal in a respirator, as recommended 
by Dr. Stenhouse, may prove a safeguard against infection, can only 
be proved by extensive trials; and in this as well as in many other ap- 
plications, it well merits the attention of the profession. Its utility 
in gangrene and fetid abscess of the lung, in empyema, and advanced 
stages of tuberculous disease, can scarcely be questioned. 

The other remedies, to be opposed to the influences of zymotic poi- 
sons, are stimulants, which counteract their depressing influence ; tonics, 
which, by increasing the tonicity of the vascular system, prevent the 
visceral congestions which are among their worst effects ; and eliminants, 
which promote the expulsion of the poisons%from the body. The ap- 
plication of these remedial agents in the cure of zymotic diseases, be- 
longs to special therapeutics ; but their use as preventives, to counteract 
the operation of the poisons, as exciting causes, is worthy of attention 

1 Dr. Stenhouse has shown that charcoal has no antiseptic property in itself; in fact 
it hastens the decomposition of any organic matter with which it is placed in contact. 
Its purifying influence depends on its property of absorbing and condensing in its pores 
any gases or vapours, and by this condensation promoting their oxidation and conversion 
into innocuous matters. Thus sulphuretted hydrogen is converted into sulphuric acid 
and water; carburetted hydrogen into carbonic acid and water: cyanogen into carbonate 
of ammonia, &c. 



94 



EXCITING CAUSES OF DISEASE. 



in this place. It has often been remarked that a considerable propor- 
tion of the persons who are exposed to malaria or infection do not con- 
tract the diseases which result in other cases, and yet some exhibit 
proofs that the poison has really entered their system. Thus in aguish 
districts a healthy person may have a severe headache ; but this soon 
passes off. During the prevalence of scarlatina, such an individual 
may have a sore throat of a day's duration ; and when cholera prevails, 
few escape without more or less of a transient diarrhoea. But the 
morbific influence goes no farther, being successfully resisted and pro- 
bably expelled by the natural powers. Now there may be others in 
whom these natural powers are inadequate to this task, unless they are 
aided by some of the remedial agents before mentioned. Thus to per- 
sons with languid circulation and deficient strength, a moderate amount 
of wine or other proper stimulant, judiciously combined with food at 
meals, may supply the wanting vigour of resistance. To those with a 
weak soft pulse, with consequent liability to congestions, small doses 
of quinine, or other tonic, repeated twice or thrice daily, may sustain 
the balance of the circulation against the operation of the cause ; and 
finally, to those whose excreting functions are torpid, the assistance of 
such medicines as may moderately augment the defective excretions, 
may prove the means of delivering them from the ulterior effects of the 
poison. In illustration of this last suggestion I may adduce the well 
known fact ascertained by Orfila, that arsenic and other poisons might 
be given to animals without deleterious effect, only so long as they were 
combined with diuretics and other eliminants. 



95 



CHAPTER II. 

PATHOLOGY (PROPER) — THE NATURE AND CONSTITUTION OF DISEASE. 

106. Disease is a change from the natural condition of the function 
or structure of the body, (§ 6, et seq. ;) but the change is generally 
more or less complex, involving several elementary functions or struc- 
tures ; it is therefore obvious that we cannot obtain an accurate know- 
ledge of the nature of disease, until we have carefully studied the 
component parts of which it is made. As the anatomist or physiologist 
examines structures and functions by separating or analyzing them 
into their constituent parts, before he enters on their contemplation as 
a whole, so should the pathologist study the constituent parts, or ele- 
ments, of disease, before he attempts to understand their combinations. 

A neglect of this precept has greatly retarded the advancement, nay, 
even the formation, of pathological science. Men enter upon the very 
complex problems of inflammation and fever, before they have made 
themselves acquainted with the elementary properties of textures, or 
even of vessels. The result has been, that the most profound reasoning 
and ingenious speculations have been wasted on such nonentities as 
spasm of the extreme vessels, and increased action of the capillaries: 
and even observation has been confused by the complexity of the sub- % 
jects that are too suddenly brought before it. 

The chemist, while pursuing his examinations, finds that there are 
some principles or elements which he cannot analyze or divide farther; 
these he calls ultimate or primary elements : others, again, he discovers 
to be compounds, which he can resolve into primary elements ; but 
which are so simple, occur so constantly, and act so distinctly in com- 
bining, and in giving properties to complex matter, that he is induced 
to name them proximate principles, or secondary elements. The phy- 
sicist or natural philosopher, makes a similar distinction in the matters 
with which he deals. 

107. So too it should be with the physiologist and pathologist. 1 There 
are the healthy and diseased primary, or ultimate elements of struc- 
ture — muscular fibre, nervous matter, vascular structure, and the ele- 
mentary tissues of membranes, glands, skin, and other like textures; 
'and there are primary elements, healthy and diseased, of the functions 

1 1 have pursued this synthetic mode of teaching general pathology, in my lectures, since 
the year 1889. I am not aware that it has been as fully used by any other writer, 
although several (among them Andral and Carswell) have partially recognised it in 
classing the objects of morbid anatomy ; and my friend, Dr. Symonds, has alluded to 
the parallel case of chemistry, and has actually employed the term, proximate princi- 
ples of disease, in the same sense in which I use it. — Library of Practical Medicine, vol. i., 
Pathological Introduction. 



96 



PRIMARY ELEMENTS OF DISEASE. 



of these same structures — irritability, tonicity, and nervous properties, 
to which we may add, because at present we cannot analyze it, the 
power of secretion and nutrition ; and lastly, there are the constituents of 
the highly important fluid which furnishes the material of the elemen- 
tary tissues, namely the blood, which are also subject to morbid altera- 
tions of structure and derangement of function. But there are also 
secondary or proximate elements of disease, composed out of these 
primary elements, but which are themselves simple, in comparison with 
the complex conditions of disease that they combine to produce. 

108. But again, disease, affecting the several elementary and proxi- 
mate structures and functions of the body, varies, both in degree and 
in hind ; the degree, including excess and defect, alterations of a plus 
and. minus nature: and kind, relating to changes not coming under 
either of these heads, but characteristically expressed by the term per- 
version. By employing these several distinctions while considering 
deviations of structure and function, we are able to construct a simple 
and comprehensive classification, which embraces within itself all the 
most important topics of general pathology. 

109. The following table presents this classification, so far as the 
primary or ultimate elements of disease are concerned. 



PRIMARY ELEMENTS OF DISEASE. 



STRUCTURAL CONSTITUENT. 

Contractile fibre 



ITS FUNCTION. 

J Irritability. 
\ Tonicity. 



DISEASE. 

1 



STRUCTURAL DISEASE. 



'Tubular (the con-^ Sensation, 
cluctor of nerve | Voluntary motion. 
Nervous J force.) I Involuntary motion, 

structure ' Vesicular (the ge- f (excited motor 
neratorandcombi- j action.) 
ner of nerve force.) J Sympathetic action. 
Secreting structure - Secretion. 

C Red corpuscles. 
White corpuscles. 
Fibrin. 
Elementary Albumen. 



components Oil, and combustive 
matters. 
Inorganic ingredients 
(saline and mineral. 
L Water. 
By respiration. 
By secretion. 
By nutrition. 
By foreign matter. 



of blood 



Elementary 
changes in 
the blood 



r Excessive. — Hypertrophy. 



\- ■{ Deficient. — Atrophy. 



[ Perverted. — Degeneration. 



110. In treating of the proximate, or secondary, elements of dis- 
ease, we are constrained to be more arbitrary and less comprehensive ; 
lest we should encroach on the domain of special pathology. There- 
are, however, certain changes in the state and action of the vascular 
system, and of the nutrient function so intimately connected therewith, 
which are of so comprehensive a character and so wide an extent, as 
to belong to the province of general pathology ; but which nevertheless 
comprise alterations in two or more of the above named ultimate ele- 
ments of structure and function (blood constituents, secretion, irrita- 
bility, tonicity, &c, § 109.) These also may be tabulated as the proxi- 
mate elements of disease. 



mOXIMATE ELEMENTS. 



97 



PROXIMATE ELEMENTS OF DISEASE. 



f Deficient in quantity f General 
— Anaemia \ Partial 



r 



^2 

to 



f General— Plethora -{ 2 3 
^ 9 



-{ Excessive in quantity 
— Hyperemia 



I Partial — Local hy- 
Perverted in quality [_ perse inia 

— Cachsernia 
Deficient — xl trophy. 
Nutrition Excessive — Kyper trophy. 

of Tex- - f Degenerations of tissues, 

tures Perverted — 1 Morbid deposits. 
[ ( Morbid growths. 



! a* 
I 6 



Increased — Sthenic. 
Diminished — Asthenic. 

Increased — Determina- 
tion of blood. 
Diminished — Congestion. 
Partly inc. J Inflamma- 
Partly dim. \ tion. 



These primary and secondary elements of disease come, then, under 
the especial notice of general pathology. By studying them we form 
an acquaintance with the materials of disease, and their general re- 
lations ; but we also learn how special diseases arise, and of what they 
consist: how they produce their phenomena and effects, and how they 
are to be known, distinguished, and classified. Out of a correct and 
sufficient knowledge of these elements, combined with the comprehen- 
sion of the properties of remedial agents, is to be deduced the rational 
method of preventing, relieving, and curing disease ; in other words, a 
rational practice of medicine. 

I readily admit that our knowledge of these elements or principles 
of pathology is as yet so limited that it cannot take rank as a com- 
plete science ; but I think that the attempt to describe and illustrate 
them will be useful, not only by communicating direct information, but 
also by pointing out where investigation is needed : thus suggesting fit 
subjects for farther research. 



FUNCTIONAL OR DYNAMIC DISEASES. 

PKIMABY ELEMENTS. 



SECTION I. 

PROPERTIES OF THE MOVING FIB EE. — IRRITABILITY. 

111. Irritability, irritable contractility, or the property of con- 
tracting on the application of certain stimuli, is the distinctive charac- 
teristic of muscular fibre.— Some physiologists, Prof. Muller and Dr, 
T 



98 



PROPERTIES OF THE MOVING- FIBRE. — IRRITABILITY. 



Marshall Hall among them, 1 maintain that this property is not inhe- 
rent in muscular fibre, but is, in some way, seated in the nervous tis- 
sue distributed on it. Many more, however, hold with the view of 
Haller, that the muscular texture itself, is intrinsically irritable, and 
that the nervous influence is but one of the many stimuli that are ca- 
pable of calling the irritability into active operation. And this seems 
the more probable state of the case — there is no doubt whatever that 
the irritability of the muscular fibre remains for some time after all 
vital susceptibility and power have been destroyed in the nerves by nar- 
cotic influence. 

There is one condition which is well known to be more or less essen- 
tial to the continued existence of muscular irritability. This is a due 
supply of arterial blood. Such a supply seems to act in a two-fold 
way. — In the first place it furnishes the material of muscular nourish- 
ment, and this is necessary, because the muscular movement is a. de- 
structive or disintegrating process — some portion of the muscular sub- 
stance is destroyed with every movement which it makes. But in the 
second place, arterial blood furnishes the oxygen which is requisite to 
effect the disintegration of the organized material. It is an interesting 
fact that the continuance of muscular irritability after the general 
death of the system, is generally proportioned in different species of 
animals to the activity of the respiratory functions. Where the re- 
spiration is the most active, muscular power is the greatest. Muscular 
contractility is, however, less dependent upon the presence of oxygen 
in cold-blooded animals than in warm, and involuntary muscles also, 
are somewhat more independent of its influence, than voluntary — the 
heart continues to contract for some time after venous blood alone is 
supplied to it, and after all circulation in its coronary vessels has ceased. 
M. Brown Sequard demonstrated the power of arterial blood to cause 
the contractility of muscular fibre in a very ingeniously devised ex- 
periment. He found that in the body of a decapitated criminal, all 
trace of muscular irritability had disappeared twelve hours and a half 
after death, and cadaveric rigidity supervened. Forty-five minutes 
after this, he began to inject arterial blood into the veins by half-pints 
at a time. He continued to do this at intervals for 35 minutes, and 
he then found that several of the muscles had regained their irrita- 
bility. It is highly probable that the contractile power is a direct re- 
sult of chemical decomposition of an oxidizing kind. MM. Becquerel 
and Breschet have shown that heat is disengaged during muscular con- 
traction, and Prof. Matteucci thinks that he has proved the evolution 
of electricity by means of his "frog galvanoscope." Some recent mi- 
croscopical observations, made upon some very beautiful specimens of 

1 Dr. M. Hall ascribes irritability to the spinal marrow; but he mentions an experi- 
ment which is conclusive against his own view: — "During the half lethargic condition of 
the frog in winter, the entire cerebrum and spinal marrow may be removed, by slow 
degrees, at considerable intervals; the circulation is nevertheless good." — Gulstonian 
Lectures, 18-12, p. 60. The irritability of the heart, therefore, is unimpaired by the 
removal. The experiments of the late Dr. John Reid, on muscular irritability, go far to 
prove that it is a vis insita. Mr. Bowman and others have seen, with the microscope, 
a single muscular fibre exhibit contractile power, when freed from all attachments and 
nervous connexion. 



IRRITABILITY — ITS NATURE. 



99 



muscular fibre prepared by Mr. Lealand seem to indicate that these 
chemical changes operate mechanically by causing the cells or vesicles 
of which the ultimate muscular fibres are composed, to change their 
dimensions. 1 Professor Carpenter considers that the ultimate fibres 
of muscles are made of rows of drum-shaped vesicles placed end to end, 
and adhering together by their flattened surfaces, and he thinks that 
these vesicles severally contract their longitudinal dimensions, and 
bulge out their sides, whenever the fibre is shortened. In this view 
the oxidation of the complex organic principle contained within the 
vesicle (probably globulin and hsematin,) causes change in its form, 
and the change of form in several vesicles produces the contraction of 
the fibre. 

This property of the muscular fibre may become excessive, so that 
its contraction is too violent for the welfare of the part, or of the sys- 
tem at large. This constitutes spasm or convulsion. Excess of irri- 
tability manifests itself in three different ways: — 1. By moderate 
strength and force of contraction; 2. By inordinate quickness or 
promptitude of contraction; 3. By unusual duration of contraction. 

112. (1.) Excessive strength of muscular contraction is exemplified 
in the violent action of the heart and other muscles during great ex- 
ertion and excitement ; and also in the extraordinary efforts of delirious 
patients, who can master persons ordinarily stronger than themselves. 
This exaltation of the natural property may depend on undue stimulus, 
as when too much blood passes through the heart, or when too much 
nervous influence is developed, as in the case of the delirious patient ; 
or it may arise from the muscles being over-fed with blood, which hap- 
pens in the continued increased action of the heart, where there is ten- 
dency to hypertrophy. It is probable that when extraordinary efforts 
are made during delirium and mental excitement, these are effected in 
consequence of a greater number of muscular fibres being simulta- 
neously called into play, rather than in consequence of the fibres being 
then more strongly contracted. 

113. (2.) Inordinate readiness or quickness of contraction consti- 
tutes high mobility of muscle, a very slight stimulus being then suffi- 

! cient to induce it to contract. This often co-exists with want of power 
or completeness in the contractions. It is exemplified in the irritable 
heart, which, although acting very frequently, does not expel its con- 
tents so vigorously as in health ; so that whilst its own action is strong, 
the pulsations in the vessels of remote parts are weak, and the limbs 
partially cold. It is seen in the quick nervous movements of irritable 
persons, who are at the same time wanting in tone. The bowels show 
it in that irritable looseness formerly called lientery, in which food is 
quickly passed little altered ; and it is instanced in the irritable blad- 
der, which will not hold even an ounce of urine. The pathological 
cause of this kind of inordinate irritability is either an undue flow of 
blood to the muscle, sometimes combined with an irritating quality in 
the blood itself, or a predominance of irregular nervous influence, which 

1 Carpenter's "Principles of Hum. Phys.," p. 296. Dr. Sharpey's "Quain's Ana- 
tomy," fifth Ed., p. 1G8. 



100 PROPERTIES OF THE MOVING FIBRE. — IRRITABILITY. 



unduly excites the contractility: thus it is often induced by irritations 
applied to the motor nerves. The most remarkable example of this 
kind of diseased contractility is exhibited in the extreme case of con- 
vulsions or clonic spasms — that is, sudden contraction, alternating with 
relaxation; this is seen in chorea, epilepsy, and convulsive hysteria, 
where it affects the voluntary muscles ; and in the palpitating heart, 
which beats irregularly and out of rhythm. 

114. (3.) An unusual duration of muscular contraction constitutes 
tonic spasm or cramp, in which the action is strong, continued, and not 
alternated with relaxation. Such spasm is not unfrequently felt in the 
calves of the legs ; and is sometimes experienced in the different mus- 
cle-covered canals, the gullet, the stomach, the intestines, the glottis, 
and the bronchi. In most of these cases, the contraction is accom- 
panied by pain more or less severe, and may lead to serious obstruc- 
tion to the function of the affected organ. When in a more moderate 
degree this form of disordered contractility is present and affects the 
voluntary muscles generally, it constitutes catalepsy, in which, the 
limbs retain whatsoever attitude they are placed in, until the spasm is 
over. Id its extreme condition it is known as tetanus, in which the 
spasms are so violent and so enduring, that they may be said to squeeze 
the patient to death. The pathological cause may be in this, as in 
other modifications of irritability, either an irregular supply of blood 
to the muscle, or irritation, direct or indirect, of the motor nerves by 
which the muscles are excited. 

115. Remedial measures. — These should depend on the cause of the 
excessive irritability. Where there is increased flow of blood to the 
part, blood-letting, the application of cold, derivants, sedatives, and 
other remedies suitable for the removal of determination of blood, will 
be proper. Firm and continued pressure on muscles affected with 
spasm or cramp, will promote their relaxation. I have succeeded in 
opening the jaw in trismus, by using strong steady pressure on the 
masseter muscles. Where the cause is nervous irritation, narcotics 
are the most effectual remedies ; and some of these, from their peculiar 
efficacy in allaying spasm, are called antispasmodics. The most power- 
ful are, stramonium, belladonna, sulphuric ether, chloroform (taken 
into the stomach or inhaled,) opium, and Indian hemp. Where irrita- 
bility is combined with weakness, tonics are often serviceable, especially 
the metallic preparations and bark. In such cases the muscles are 
usually weak and ill-nourished, and their excitability is dependent on 
exalted function of the excitomotory nerves; the remedies adapted to 
this state of things will be noticed when speaking of nervous diseases. 

116. Muscular contractility may be deficient in either of two ways. 
(1.) It may be wanting in force (§ 112;) as when the voluntary mus- 
cles are weakened during severe illness, after fatigue (§ 68,) or under 
the influence of a depressing poison or shock (§ 55;) the same is also 
illustrated in the debility of the heart under similar circumstances, in 
faintness, and in the sinking which precedes death. Weakness of this 
kind may be caused by exhaustion from previous exertion, or by want 
of the due supply of blood necessary to maintain the muscular function 
(§ 111;) or it may proceed from an influence which positively depresses 



DEFECTIVE — REMEDIES 



101 



or destroys the muscular power, as when sedative poisons like tobacco 
and sulphuretted hydrogen are taken ; and probably concussion and 
other violent injuries to the organization act in the like way. The ex- 
treme effect of these agents is that they cause paralysis, or complete loss 
of irritability, which, affecting the heart, constitutes death by syncope. 
Muscles sometimes lose their irritability in consequence of the opera- 
tion of more gradual causes, like rheumatic inflammation, the action of 
lead, &c. Muscles *may be reduced in power by over-excitement or 
exertion on the one hand, but so also they may by disuse on the other : 
this is exemplified in the paralysis of the sphincter which follows from 
over distention of the bladder, torpor of the bowels which ensues after 
the operation of an active purgative, and in the weakness and ultimate 
palsy of the muscles of an anchylosecl limb. 

117. (2.) Muscular contractility may be deficient in readiness to act 
(§ 113,) as seen in the sluggish movements of persons whose muscular 
irritability has been lowered by opium ; and evinced in the slow pulse 
caused by digitalis, and by some cerebral affections ; in some cases also 
by blood-letting or low diet. It is by no means clear why the same 
agents should, in some cases, lower the strength, and in others retard 
the readiness to contract: in many other respects, also, the laws of irri- 
tability require farther investigation. A benumbing degree of cold 
greatly reduces the irritability of the muscles ; yet the sudden dash of 
cold water will sometimes restore contractile power which has been re- 
duced by exhaustion or sedatives. 

118. Although it has been shown to be most probable that muscular 
irritability is not derived from the nervous system, yet it is no less 
clear from the illustrations already given that it is very much under 
its influence. Nervous action is the stimulus provided for calling up 
the latent and inherent contractility of the voluntary muscular fibre; 
and through the nerves the motions of the involuntary muscles also are 
influenced, as instanced by the operation of mental emotion on the ac- 
tion of the heart (§ 69.) Hence diseases of muscular action rank with 
nervous diseases. Thus, disease of the brain may cause a cessation 
of muscular motion by suspending volition; and disease of the spinal 
marrow, or nerves, may do the same by intercepting the influence of 
the will: in either case, motion of the muscle ceases, not from disease 
in itself, but for want of its proper stimulus. In fact, under these cir- 
cumstances, muscular irritability sometimes accumulates (§ 111,) and 
is brought into action, by slight impressions reflected from the spinal 
marrow. Thus, in complete paraplegia, or loss of motion of the lower 
half of the body, convulsive movements may be excited in the lower 
extremities by tickling the soles of the feet or merely pinching the skin : 
in other cases of paralysis, they may be produced by electricity. 

119. Remedial measures. These, of course, should vary with the 
cause of the defective irritability ; where this proceeds from exhaustion 
following long-continued exertion, repose is obviously necessary. But 
even here, in extreme cases, and more particularly if of the nature 
specified in the second division (§ 117,) it may be necessary at once 
to excite the deficient irritability by stimulants, especially of the more 
diffusible kind, such as ammonia, brandy, other spirits, and essential 



102 



PROPERTIES OE THE MOVING FIBRE — TOXICITY. 



oils ; at the same time the feeble circulation may be aided bj the use 
of heat and frictions. The large quantity of stimulants that can be 
borne by patients whose irritability has been reduced by accident or 
disease, is a remarkable feature in their history. A person faint from 
great loss of blood (§ 71,) a crushed limb (§ 52,) an extensive burn, or 
a sedative poison, Avill bear four or five times more brandy than would 
be sufficient to intoxicate him under other circumstances. Electricity 
and the dashing of cold water, should be mentioned among the means 
that serve temporarily to excite defective irritability. Strychnia and 
cantharides given internally, are reputed to restore power to paralyzed 
muscles ; but the same agents act much more energetically when directly 
applied to the affected part through blisters. So likewise stimulant 
frictions, warm douches, and other means that tend to promote a vigo- 
rous circulation throughout the weakened muscles may assist in re- 
storing their strength: generous diet, with tonics and healthy air, 
render the blood richer in the plastic matters by which the muscles are 
nourished. 



SECTION II. 
PROPERTIES OF THE MOYIXG FIBRE — TOXICITY. 

120. Toxicity, or tone, is a property possessed by all muscular 
structures, whether voluntary or involuntary, as well as by some other 
textures which are hardly accounted muscular. It is expressed by a 
tendency to slow, moderate, and permanent contraction, not essentially 
terminating in relaxation ; it keeps the parts in which it resides in a 
certain degree of tension. It is seen in the retraction of a living mus- 
cle when divided in the operation of amputation of a limb, which takes 
place to a considerably greater extent than it would in a dead muscle. 
It holds muscles and limbs in their places when at rest, and out of 
their places when dislocated: when one set of muscles is paralyzed, the 
tone of their antagonists draws the parts in connexion with them in an 
opposite direction, as seen in paralysis of the portio dura of one side of 
the face. A similar property is exhibited by the intestinal tube, the 
urinary bladder, and the air tubes ; it also resides in the middle coat of 
the arteries, and gives those tubes a constant tendency to contract on 
their contents. This is shown when they cease to receive blood from 
the heart; their tonicity then narrows their calibre, and thence they 
are always found empty after death. It also adapts them to different- 
degrees of fulness, and yet maintains in their walls the tension that is 
favourable to equality in the motion of the blood. Tonicity performs 
an important part in the phenomena both of health and disease. 

It has been stated, that tonicity is quite distinct from irritability ; 
and that, although irritable fibres possess tone, tonic textures are not 
irritable. This however is not true with regard to the arteries ; for I 
have many times distinctly seen them slowly contract, and remain con- 
tracted, at a point to which an irritant, (mechanical, chemical, or elec- 



DISTINCTION BETWEEN IRRITABILITY AND TONICITY. 103 



trical,) lias been applied. The discovery, by Hcnle, of a structure dis- 
tinctly muscular in arteries, confirms this observation. I have, in like 
manner, satisfied myself of the irritability of the air-tubes, which move 
more rapidly under a stimulus than the arteries; the intestines do the 
same in a still higher degree, but still inferior to that of the oesopha- 
gus and voluntary muscles, the contractions of which, on the applica- 
tion of a stimulus, are abrupt, and immediately followed by relaxation. 
So far, then, it appears, that the slow contraction of tonicity is in- 
fluenced by the same agents which excite irritability ; but there is ano- 
ther agent, temperature, which seems to affect them differently (§ 74, 
75.) Cold, which impairs irritability, increases tonicity. — Under the 
influence of cold, vessels generally, but especially arteries, shrink in 
size very remarkably; 1 and the muscles and other textures, under the 
same circumstances, present a firmness and vigour of tonic contraction, 
which impede the quickness of motion that characterizes the highest 
degrees of irritability. Under the influence of heat, on the other hand, 
muscles are more relaxed, and more irritable : the pulsations of the 
heart are made by it more frequent. 

Cold and heat, therefore, become excellent tests of the presence of 
tonicity; and by their means it is found that this property is possessed 
by textures, which are not distinctly muscular ; the veins and the cutis, 
■which contract remarkably from cold, and are relaxed by heat, 2 are 
illustrations of this. 

Now tonicity is a very important property in the animal economy ; 
its presence in the normal state is very necessary for the preservation 
of health, and its abnormal modifications are concerned in causing and 
constituting disease, more particularly in the vascular system. Prac- 
tical men have long felt the existence of something of this kind, with- 
out being able to define or localize it ; the terms tone and atony, bracing 
and relaxing, in such frequent use, are proofs of this. We proceed to 
notice some of the results of excess and defect of tone. 

121. Where there is an excess of tonicity, the muscles are so firm 
that there is scarcely room for supple motion; the pulse is hard, and 
tense, and it may be frequent or slow, but in either case there is 
scarcely any interval between the heart's beat and the radial pulse. 
The capillary circulation is active, and the extremities warm ; but owing 
to the tense state of the vessels and of the skin, the secreting organs 
do not act freely, the urine is high-coloured, the bowels are disposed 

1 This fact must Tbe familiar to every one who has noticed the difference of the pulse 
when a limb is cold and when it is warm. But I have seen it more forcibly illustrated 
by experiment. On plunging into cold water the aorta of an ass just dead, it contracted 
so closely as to obliterate its cavity; and it required some force to pass the little finger 
into it. The crimping of the flesh of fish is referable to the same principle. 

2 It is difficult to assign the limit between textures that are irritable and not irritable. 
Thus some large venous trunks, as the cava, have been found by Valentin to exhibit 
slight contractions on the sympathetic nerve being irritated; and fibres, like those of an 
unstriated muscle, have been found in their coats. The irritability of the dartos is well 
known; and I have frequently seen the skin of the trunk and limbs contract, and cause 
the projection of the papillse (presenting the appearance of the cutis anserina,) on 
gently scratching or tickling it, the appearance being confined to the vicinity of the part 
tickled. 



104 



PROPERTIES OF THE MOVING FIBRE.— TONICITY. 



to be costive, and the skin to he dry and hot. The vascular system 
is in a state of such high pressure, that any weak part may give way, 
and induce local congestion or flux, active hemorrhage or inflammation, 
apoplexy or gout ; but there is less than usual proclivity to suffer from 
cold, endemic and infectious poisons, and other influences of a like de- 
pressing character. The causes which produce excessive tonicity are 
an over-nourishing and stimulating diet, with want of sufficient exer- 
cise; a dry bracing air; tonic medicines, such as iron and bark; the 
excitement of fever ; and the occurrence of other disorders in which the 
blood becomes over-heated or over-stimulating from the presence in it of 
irritating matters, such as lithic or lactic acid, and other products of 
imperfect assimilation, or other results of defective depuration. 

122. Remedial measures. — In such a state blood-letting and other 
evacuant measures serve to reduce the tension and excitement of the 
vascular system, but still the fibres may remain too much braced, and 
the pulse too hard, and the secretions defective ; then the vessels soon 
fill again and the evil is renewed. The measures most likely to remove 
this morbid state of excessive tone are such as tend to relax the braced 
fibre, and increase the secretions ; for instance warm bathing, exercise, 
the use of sudorifics, aperients, and diuretics, and a moderated diet. 
Some remedies, (antimony) seem to directly reduce the tone of the 
vascular fibre, and so act as relaxants. We shall have to advert to 
this subject again when speaking of inflammatory fever, in which ex- 
cessive tone of the vascular system is one essential condition. 

123. Where tonicity is defective, the muscles are flabby and incapable 
of continued exertion, and sometimes they are too irritable, and affected 
with the tremulousness of debility (§ 113.) The heart likewise is irri- 
table, and exhausts its strength in palpitation ; the pulse is soft and 
yielding : it is often full when slow, and sharp when frequent ; but it 
is without firmness or endurance, and is easily accelerated. Another 
distinctive character of this condition is retardation of the ordinary 
wave of the pulsation, the interval between the heart's beat and distant 
pulses being increased; so that the radial pulse is often felt after the 
second sound of the heart is heard (§ 121 ;) the pulse wave is slower 
than usual (§ 120,) because the vascular tubes are less tense. Some- 
times the absence of that tightening of the walls of the arteries whereby 
the internal movement is ordinarily controlled, permits their mechani- 
cal elasticity to come into play; and this reacting after each stroke 
of the heart gives that peculiar reduplication or rebounding of the 
pulse, which has long been described under the term dichrolous. This 
is often observed in convalescence from fevers, and other analogous dis- 
eases after the subsidence of vascular excitement; the state of excessive 
tone being followed by one of consequent atony. (121. l ) A loose re- 
laxed state of the vessels renders the circulation in distant parts weak, 
so that the extremities become cold, whilst the head and internal or- 

1 One very important effect of hyper-tony of the vascular system is the rendering it in- 
tolerant of some medicines. Thus it is frequently found that patients, otherwise weak, 
do not bear tonics well because the vessels are more or less already in an excited state 
from the presence of gouty or rheumatic matter in the blood. Then so soon as this 
matter is expelled tonics are easily borne, and render good service. 



DEFECTIVE TONICITY. 



105 



gans are congested. Sudden exertion or change of posture may under 
such circumstances so disturb the circulation as to cause faintness or 
giddiness. Want of tone in the stomach and intestines favours indi- 
gestion and costiveness, and causes these organs to become distended 
with wind and accumulating faeces. From the secreting organs being 
irregularly supplied with blood, the secretions are also liable to get 
disordered, and to be either scanty and depraved, or profuse and 
watery. 

It is quite obvious that a person in such a condition of relaxation 
must be prone to various diseases. He has very little power (§ 85) to 
resist malaria, infection, or other depressing influences. If he is ex- 
posed to cold, the blood is readily driven through the weak vessels into 
the interior (§ 79,) and there causes congestion or inflammation. The 
debilitated intestines have no power to expel offending matter from 
them (§ 57.) The system, in this state of atony, is in many respects 
on the verge of disorder, especially congestion and its consequences, 
and other derangements of the circulation, as well as being particu- 
larly predisposed to suffer from all the various exciting causes of dis- 
ease. 

The causes of loss of tone are various debilitating influences (§■ 28, et 
seq.,) such as continued and exhausting excitement of the vascular 
system (§ 64,) continued exposure to heat, especially if with moisture, 
confinement in impure air, defective nutrition (§.63,) imperfect excre- 
tion (§ 68,) &c. Muscles lose their tone from want of exercise, and 
blood-vessels theirs from the long continued operation of cold (§ 77.) 
The tonicity of the arteries is remarkably influenced by the state of 
the nervous system; we shall hereafter find that a relaxation of the ar- 
teries of the part is the chief cause of local determinations of blood. 

124. Remedial measures. — The proper remedies for defective to- 
nicity are tonics, that is agents which tend to increase the tone of the 
whole system (§ 120,) but particularly that of its muscular and vascu- 
lar structures. It has already been stated that cold has this effect in 
a marked degree (§ 30,) and in truth, cold, properly applied, is one of 
the best tonics which we possess. But to effect this purpose its appli- 
cation should be sudden and not sufficiently continued to cause depres- 
sion or any other morbid effect. The shower-bath and plunge-bath are 
the most effectual forms in which it can be used; and free sponging, 
with cold salt water, is suitable even for weak subjects. Free exposure 
to a pure bracing air, and moderate exercise taken at the same time, 
have also marked tonic effects. There are many medicinal tonics, the 
most effectual of which are bark and its preparations, such as quinine, 
cinchonine, bebeerine, and salicine; also preparations of iron, arsenic, 
zinc, copper, and the mineral acids. Generous living has itself a tonic 
influence, in so far as it tends to enrich the blood, which sustains to- 
nicity as well as all other vital properties. 1 

1 It appears to me highly probable that the efficacy of tonics and antiperiodics in in- 
termittent, remittent, and typhoid fevers, as well as in neuralgia and other disorders, in 
which internal congestion without inflammation is present as an element, may be 
ascribed to the property that is implied in their name, — that of restoring deficient tone to 
the vascular system. At an early period in these diseases, before the functions have 



106 



ELEMENTARY NERVOUS FUNCTIONS. 



SECTION III. 
ELEMENTARY NERVOUS FUNCTIONS. 

125. The functions of the nervous system are now generally resolved 
into — 1, those of the nervous centres, parts which generate and com- 
bine nervous influence and force, and 2, those of the nerve trunks and 
branches, parts which conduct this influence or force to or from the po- 
sitions in the body, in which the agency is required. The functions 
of the nerves are also farther distinguishable as being of the nature, 
either of sensation — voluntary motion — involuntary motion — or sym- 
pathy. 

It is difficult to separate these primary elements of function concerned 
in the production of disease from the complex combinations in which 
they generally are presented in the phenomena of animal life, and 
which in strict accuracy should be treated of under the denomination, 
either of proximate elements of disease, or of special disorders of the 
nervous system. In order to avoid the need of future repetition, an 
outline is, however, here introduced of the most elementary functions 
of the nervous system, and of such of their proximate combinations, as, 
acting in excess, in deficiency, or in perversion, may become influential 
in the production of morbid deviations from the standard of health. 

It may be premised that every nervous function is susceptible of 
certain variations, in accordance with changed conditions of structure. 
Of these some are ascertained, and serve to illustrate aptly certain im- 
portant points in pathology and therapeutics. These nervous functions, 
in common with all others, are excited by increased flow of blood 
through the tissues that are their seat; and they are depressed by its 
diminished flow, or by its stagnation in the vessels. But these func- 
tions depend, not only on the quantity and continued motion of the 
blood, but also on its quality; hence they are liable to be influenced by 
whatever alters the composition of the blood, for instance, the reten- 

become much, disordered, or the blood very much depraved, a few large doses of quinine 
often succeed in effecting a cure. The power which this remedy possesses to remove 
congestion appears to be closely connected with its curative agency. In more advanced 
stages of these diseases, when the disorder has become inveterate, and the depraved se- 
cretions and altered blood indicate that there is something beyond mere want of vascular 
tone, the efficacy of quinine is very much less; it may even aggravate the symptoms if 
continued febrile action have intervened. Eliminants, — agents that augment the excre- 
tions, and through them carry off the offending effete matter, then need to be premised; 
or they may be given with tonics, whose operation may be expected to be beneficial, 
although not in the same rapid and decided way, as when vascular atony is the sole in- 
gredient of disease. The congested state of the blood-vessels after the subsidence of 
neuralgic pain, or even of inflammation, is another condition in which the speedy and 
satisfactory action of tonics may be looked for. I have often had occasion to notice that 
certain paroxysmal nervous diseases, like epilepsy, chorea, hysteria, cardiac palpitation 
and asthma, are associated with an atonic state of the vascular system, for which tonics 
are the best remedies. As an empirical fact, this is fully recognised, but the obvious 
explanation has not always been kept in view. 



SENSIBILITY — CENTRIC — EXCESSIVE. 



10T 



tion of excrementitious matters (§ 68) the presence of poisons (§§ 56 — 
72 — 73 — 82 — 105) the predominance of chemical affinities beyond what 
is salutary for the wear and renovation of the tissues (§ 53) as when a 
septic or putrescent tendency exists in the body. — But in addition to 
these causes of nervous derangement, acting through the circulation 
(which are of the most frequent occurrence,) there are others to be 
mentioned, which operate more directly upon the nervous structure 
itself; of this nature are mechanical irritation, heat, cold, electricity, 
and mental emotion. — Mechanical irritation, applied either to a ner- 
vous centre, or to a nervous branch, excites its function, but in conse- 
quence of the high mobility of the structure concerned, this excitation 
is very apt to extend from one part to another of the nervous system. 
— Very severe mechanical injury acts, too, like a universal shock, de- 
pressing or suspending the vital functions, not only of the parts injured, 
but also of other portions of the nervous and muscular apparatus. — 
Heat, within moderate limits, acts by exciting nervous power; and cold 
has the opposite effect, and although a portion of the influence of these 
agents must be due to their operation on the circulation, it seems pro- 
bable that there must also be some more direct effect, for a certain de- 
gree of warmth is essential to the maintenance of all the vital proper- 
ties. — Intense electricity is a powerful excitant of the nervous functions, 
especially of the motor ones : somewhat of an opposite effect is, on the 
other hand, produced by atmospheric electricity, which often depresses 
nervous energy in a very remarkable degree. — Similar opposite in- 
fluences may be observed in the action of mental states on the nervous 
system. 

Under whatever circumstances the nervous function is excited, its 
operation is attended with an expenditure or decay of nerve-substance, 
(as we found to be the case with respect to muscular action) (§ 111,) 
and the results of this expenditure are conveyed through the blood to 
be excreted by the kidneys. Hence under great nervous excitement 
there is an increase of the phosphates in the urine, derived from the 
oxidation of the phosphorized fat of nervous matter. 

Sensibility. — Centric. 

126. The term centric sensibility may be applied to the functions of 
the posterior columns of the spinal marrow, the corpora restiformia, 
and other parts of the nervous centres most directly concerned in sen- 
sation ; but as these structures are also the sources of the sensibility of 
other parts of the body, their influences may be extended, and become 
more or less general throughout the system, and thus disorders of cen- 
tric sensibility may also be disorders of general sensibility, while modi- 
fications of local sensibility are more usually connected with the func- 
tions of individual nerves. 

Diseases of centric sensibility may consist of either — 1, excess; 2, 
deficiency; or 3, perversion. 

(1.) Excessive sensibility is more or less present, when the nervous 
centres are excited in the early stage of inflammation or of determina- 
tion of blood in the head or spine ; where there is intolerance of light, 
noise, and motion. A similar condition exists in hydrophobia and te- 



108 



ELEMENTARY NERVOUS FUNCTIONS. 



tanus, from mere irritation without inflammation, and in the early stage 
of many febrile disturbances of the synocha class, in which there is 
quickened circulation without any stupifying influence. But sensibi- 
lity is also excessive in some persons, either congenitally (§ 41,) or a3 
a consequence of disease (§ 31, 34.) Such persons are commonly called 
nervous ; they are worried with trifles ; startled at shadows ; distracted 
by noise or bustle; never free from some ache or pain; almost every 
feeling is suffering; what in others would be slight pain, in them 
amounts to agony. Hence they are perpetual invalids, quite unfit for 
the rugged path of life, over which they walk, as it were, bare-footed 
and thin-skinned. If real disease attack them, its nervous symptoms 
are so much exaggerated, that a medical attendant is apt to fall into 
the error of either ascribing all to "the nerves," or of estimating the 
disease by the severity of the symptoms. This over sensibility is gene- 
rally conjoined with excess of irritability, and want of tone (§ 113, 
123.) Other nervous functions, such as sympathy and reflex action, 
are also often excited, or in disorder. The symptoms connected with 
sensation most frequently present are neuralgic pains of various parts, 
excessive sensibility of the surface, headache, pain in the back or left 
side, and spinal tenderness. 

127. The pathological cause of increased general sensibility is pro- 
bably excitement, either from the slighter influence of the same cause 
which acts in the early stage of encephalitis, namely an excessive sup- 
ply of blood to the posterior columns of the spinal marrow, the corpora 
restiformia, and the parts of the cerebral mass concerned in sensation, 
or from some other irritation more directly applied to these parts. 
Local determination of blood may be the result of original development; 
or it may be the consequence of inflammatory affections of the ence- 
phalon, of undue mental exertion or moral emotion, of irregularities 
in the menstrual functions, or of the reaction ensuing after great losses 
of blood; all of which states are known to be the occasional precursors 
of morbid sensibility. On a future occasion, when treating of the 
subject of irregular distribution of blood, we shall endeavour to point 
out why great losses of this liquid, and other causes of sudden weak- 
ness, are liable to be followed by excessive sensibility. The extreme 
refinements and luxurious habits of the upper classes, involving more 
excitement for the mind than exercise for the body, and for the feel- 
ings than for the understanding, are well calculated to foster this over 
sensitive state. The female sex is proverbially more sensitive than 
the male, and this appears to be due, not only to original conformation, 
but also to sedentary and enervating habits, and the want of the in- 
vigorating exercise and fresh air which give robustness to the frame. 

128. Remedial measures. — The medicinal influences most directly 
opposed to excessive general sensibility are narcotics or anodynes, 
such as opium, henbane, hemlock, Indian hemp, belladonna, chloroform, 
and ether, administered internally, or, in some instances, applied exter- 
nally, as when a soluble salt of morphia is sprinkled on the skin de- 
prived of its cuticle by a blister. All these agents diminish nervous 
sensibility; and, in proportion as this is exalted (§ 126,) the system 
generally bears larger doses. But where the increased sensibility de- 



EXCESSIVE GENERAL SENSIBILITY — REMEDIES. 



109 



pencls on inflammation, or vascular excitement of the nervous centres 
(§ 127,) the more fitting treatment is obviously that which will be here- 
after described as antiphlogistic. 1 Again : where the excessive sensi- 
bility arises from the nervous excitement of irregular circulation, from 
general weakness (§ 116) and from loss of tone, (by no means an un- 
common combination,) tonics (especially the metallic) (124) and stimu- 
lants (119,) with, or without narcotics, are the proper remedies. 2 Weak- 
ness, softness, and slow transmission of the arterial pulse (123,) and 
absence of fever or permanent heat of skin, are the chief symptoms of 
such a condition. In this state stimulants act speedily, and tonics 
more slowly, but more enduringly, by equalizing and invigorating the 
general circulation, and thus relieving the nervous centres. But coun- 
try air and exercise, cold or tepid bathing, especially in the mode of 
the shower bath, plain food for both mind and body, early hours, and 
an avoidance of all enervating habits, are often more conducive to the 
cure than medicines. 

An anodyne influence more powerful in degree, than that exercised 
by any other agent, although but transient in duration, is that result- 
ing from the inhalation of the vapour of chloroform or of sulphuric 
ether, which has during the last few years been extensively introduced 
into practice with a view to render the body insensible to the pain of 
parturition, of surgical operation, or of disease. These agents, and 
nitrous oxide gas (which has a similar effect when used in the same 
way,) act on the sensorium, rather than merely on the sensitive nerves. 
In most instances, if the inhalation be continued for a sufficient time, 
it induces complete insensibility to pain. In many cases, however, 
and especially where the inhalation has been less prolonged, or where 
the air has been less impregnated with the anodyne vapour, sensibility 
is blunted, but not destroyed, and the patient makes movements and 
utters expressions indicative of slight pain, but has no recollection of 
it when restored to consciousness. The memory seems to be more af- 
fected than the perceptive function. The power of voluntary motion 
is suspended in about the same ratio as sensibility; but the insensible 
reflex motions of the eyelids, of breathing, &c, are modified, but not 
abolished, unless the inhalation be continued so long as to induce 
complete asphyxia. 

The operation of these vapours is obviously of a narcotic kind, like 

1 Cases of generally increased sensibility, having some resemblance to cerebral or spi- 
nal meningitis, occur not uncommonly, and are known by the name of spinal irritation. 
These present a great diversity of symptoms, more or less of an hysterical character, but 
one almost constant sign is excessive sensibility of the surface, which is most intense near 
the spines of some or other of the vertebrae. In my experience this affection is not per- 
manently benefited by antiphlogistic treatment, but rather by mild tonics, and locally 
soothing the irritated spine by means of topical narcotic applications, tepid or cold 
sponging, or sometimes even douche baths. 

2 Periodical attacks of pain frequently yield to the free exhibition of quinine and other 
antiperiodic and tonic remedies; but during the paroxysm narcotics not only give tempo- 
rary relief, but by reducing the general sensibility prepare the system to bear tonics, and 
thus expedite the ultimate cure, provided they do not arrest the secretions. Its tendency 
to diminish all secretion is the chief objection to the employment of opium, which is 
therefore commonly combined with evacuant remedies, to obviate this mischievous result. 
Thus combinations of opium or morphia with mercury, antimony, ipecacuanha, colchicum, 
and salines, often agree better than the narcotic in its simple state. 



110 



ELEMENTARY NERVOUS FUNCTIONS. 



that of opium and alcohol; but is more speedy and transient, because 
it passes freely and directly through the lungs into the arterial blood, 
and so affects the brain, and because it is as promptly dispersed from 
the blood and luDgs when fresh air only is breathed. It has been 
maintained by many, that these anesthetic inhalations operate only 
by interference with the respiration, inducing a degree of asphyxia ; 
but so far is this from being the case, that their best effects are pro- 
duced when the respiration is steadily maintained ; and I believe that 
the great end to be aimed at in the administration of chloroform, is 
to narcotize, as far as possible, without too much embarrassing the 
breathing. This it is difficult to accomplish without a freer supply of 
oxygen than atmospheric air contains; and I should hence expect 
safer and more satisfactory results from the inhalation of a mixture 
of chloroform or ether vapour with oxygen gas, which might be con- 
tinued with safety for a much longer period than a mixture of vapour 
and air. 1 Since the anesthetic properties of chloroform were disco- 
vered and applied by Professor Simpson, the use of this agent has in 
a great measure superseded that of ether vapour, being more manage- 
able and agreeable, when inhaled, and more potent in its stupifying 
powers. There is, however, one peculiarity of its physiological in- 
fluence, which while recommending its employment in some instances, 
renders it highly hazardous in other cases. — It often weakens the 
action of the heart, and has induced fatal syncope, where there was 
fatty degeneration of the organ. Whenever there is great exhaustion 
of the heart's power, and especially if there is also suspicion of the 
presence of degeneration, or other extensive organic disease, chloro- 
form is a less eligible anesthetic than ether, which is more stimulant. 
In all cases'where the stupifying action is needed to be maintained 
for a considerable length of time, much circumspection should be used; 
the state of the pulse should be carefully noted, and the inhalation be 
immediately suspended so soon as insensibility to pain is induced. 

Although the chief influence of chloroform inhalation is transient, 
yet in consequence of its saving the nervous system from the shock of 
intense temporary pain during a paroxysm of suffering, it often pre- 
vents that consequent nervous irritation and exhaustion, which is highly 
injurious to the vital powers, and which predisposes to a return of the 
painful attack. In neuralgic and painful spasmodic affections, chloro- 
form not only is a valuable agent, in so far as it procures temporary 
relief, but also because by the removal of one of the paroxysms it may 
break the habit of diseased action, and so effect a permanent cure. 

129. (2.) Deficient centric or general sensibility is exemplified in 
its extreme degree in the coma, induced when the circulation in the 
sensitive centre of the nervous system is impeded by pressure, conges- 
tion, or other obstruction 2 (§ 52,) or in the stupor caused by narcotic 

1 Since this suggestion was first made, Dr. Abraham of New York lias sueeaeded in 
restoring a patient who was asphyxiated and pulseless under the influence of chloro- 
form, by the employment of artificial respiration with oxygen gas. — Canada Medical 
Journal, Jan., 1853. 

2 Dr. Fleming has produced somnolence and temporary insensibility by pressure on the 
carotids in the neck, and he thinks that this expedient might be resorted to for the pur- 



DEFICIENT CENTRIC SENSIBILITY — COMA. 



Ill 



influence. Thus when a person is in a fit of apoplexy, or poisoned by 
opium, lie has lost all feeling, as well as power of voluntary motion. 
If the blood becomes impure by the retention of excrementitious matter, 
as on suppression of urine, a like stupor occurs (§ 68.) Ansestliesia 
— that is loss of sensation — very rarely exists without loss of motor 
power. But short of these degrees, there are persons who congenitally 
(§ 41,) from disease (§ 31, 84,) or from age (§ 48,) are somewhat defi- 
cient in sensibility — feel less than other folk. All their feelings are 
obtuse and their actions slow; they have neither intense suffering, nor 
intense pleasure. Such persons have also little irritability, but much 
tone of fibre, and they are remarkable for their immunity from many 
diseases. But they are the more liable to others, such as fulness 
of blood, apoplexy, gout, costiveness, and the various evils which 
these may bring. There is one highly important difference between 
them and the over-sensitive : — disease when it occurs, may in them be 
latent, advance far, and become even dangerous before it is felt ; and 
may imperceptibly increase until it is incurable, or until sudden death 
ensues. 

130. Remedial measures.— -When obtuseness of feeling arises from 
fulness, obstruction, or pressure of blood in the nervous centres, the 
treatment should consist in attempts to remove these states by deple- 
tion, derivation, and other means to be hereafter mentioned under the 
head of disordered circulation. Where there is no actual disease pre- 
sent, but merely a torpor of the sensitive function, mental excitement, 
bodily exertion, dashing with cold water, vigorous friction, and the 
application of strong stimulants or excitants to the skin, are the best 
means of arousing the nervous system from its state of lethargy. The 
insensibility produced by narcotics, and retained excrementitious 
matters, should be combated by measures calculated to eliminate the 
stupifying matter through the natural outlets, as, for instance, the ad- 
ministration of purgatives, diuretics, emetics, &c. It is remarkable 
how promptly drastic purgatives sometimes effect the restoration of 
sensibility, in stupor resulting from imperfect action of the kidneys. 
Hysterical stupor yields as readily to the influence of turpentine or 
assafoetida enemata. It is doubtful whether we have any medicine 
capable of directly increasing sensibility. Strong tea and coffee per- 
haps have the best claim to such a property. What effect would arise 
from electrifying the spine and occiput? Stupor and impaired sensi- 
bility sometimes occur in a state of anosmia ; this is seen in cerebral 
syncope, and in children or females who have lost much blood, and is 
immediately caused by stagnation of the blood in the brain. Under such 
circumstances, the pallor of the skin and weakness of pulse indicate 
that stimulants afford the best chance of restoring sensibility. 

131. (3.) Perverted centric, or general sensibility is often mani- 

pose of preventing or relieving pain [Brit, and For. Med. Chir. Rev., April, 1855.) I 
have some doubts whether the amount of pressure required to arrest the flow in the caro- 
tids may not have injurious results, both on the vessels themselves and on the circulation 
in the brain afterwards; but the experiment is most instructive in its relation to sleep 
and coma. 



112 



ELEMENTARY NERVOUS FUNCTIONS. 



fested by persons in whom there is also increased sensibility (§ 12Gf) 
its character is presented in the peculiarity of the sensations which 
are experienced. Thus feelings of tingling, prickly heat, trickling 
cold, in various parts ; of a lump in the throat, a hot ball in the side, 
a fluttering at the stomach, and illusions of the special senses, severally 
and variously affect persons whose sensibility is modified more in 
kind than in degree. Such patients may also have a depraved appe- 
tite, craving for sour things, cinders, mortar, and all manner of filth. 
These symptoms generally occur in females, often in connexion with 
irregular menstruation, and therefore are called hysterical; but their 
pathological cause must be sought in the nervous system, the functions 
of which become deranged, probably from irregular supply or bad 
quality of the blood supplied to them. The remedial measures indi- 
cated for this condition are therefore such as are calculated to remove 
this cause : chalybeates and other tonics, pure air, nourishing food, and 
all influences which improve the quality, and equalize the distribution 
of the blood. Narcotics and sedatives may be useful as temporary 
palliatives. In rare cases, the general sensibility is perverted in con- 
sequence of structural change in the nervous centres, as for instance 
in softening of the brain ; strange and distressing sensations are then 
experienced in every part of the body. 

DISEASES OF LOCAL SENSIBILITY. 

182. The sensibility of every portion of the body depends upon its 
structures preserving their due relations with the nervous centres by 
means of the nerves. In some instances change of state in those 
centres themselves modifies the sensibility of the parts that are fur- 
nished therefrom ; this is instanced in cases of local pain or local anes- 
thesia attending on limited lesions of the brain. More commonly, 
however, alterations in the sensibility of parts depend on the condition 
of the conducting nerves which are media of communication between 
those parts and the nervous centres. 

The feeling of a part affected in this way may be excessive, deficient, 
or perverted. This may be illustrated by experiment. By irritating 
or striking a nerve, pain is produced in the part to which it is distri- 
buted, and the sensibility of the part remains exalted — that is, it feels 
tender or painful afterwards. By pressing on the nerve, a new and 
perverted sensation of tingling, pricking, and numbness, is caused. 
By pressing more strongly, or dividing the nerve, the feeling is further 
impaired or altogether destroyed. Similar effects may be produced 
by a tumour, ligature, effusion, or other cause pressing on a nerve in 
its course. Disease of the nerve, or of a part of the spinal or cerebral 
structure connected with it, may likewise modify the sensation of parts. 
Thus inflammation of the sheath of the ischiadic, or trifacial, nerve 
may cause, first neuralgic pain, and afterwards numbness in the parts 
to which the nerve is distributed. There are other painful affections 
which are to be considered and treated as cases of exalted sensibility; 
such are the (as Dr. Billing observes, erroneously so called) irritable 
breast, testicle, uterus, &e. 

133. But the function of sensation depends on the due supply of 



LOCAL SENSIBILITY — EXCESSIVE — REMEDIES. 



113 



blood to the extremities, as well as to the trunk and origin of the 
nerves. Hence if blood does not circulate freely through a limb, the 
sensations are impaired ; and if it passes too freely, the sensibility is 
exalted, and there may be itching, tenderness, or even pain. In or- 
gans of special sensation, the senses are modified, together with the 
common feeling : thus in disease of the optic nerve or retina, there are 
intolerance of light, perception of specks, (muscm volitantes,) clouded 
vision, or even blindness; in diseases of the ear, ringing and beating 
noises, or deafness, — as well as itching, tenderness, and pain, which 
are modifications of common sensation. 

134. At the external orifices of the body, and in the linings of its 
interior passages, there are peculiar kinds of sensibility connected 
with the functions of ingestion and egestion ; modifications of these 
become elements of disease. As examples of excessive sensibility in 
such may be enumerated thirst, craving, nausea, tenesmus, and urgent 
micturition: of impaired sensibility, anorexia, and loss of feeling in 
the rectum and urethra. 

135. In considering internal parts, we have only to notice sensibility 
exalted by disease. We do not know that they naturally possess any 
feeling. We are not at all conscious of such ordinary processes, as 
the passage of food and feces in the alimentary canal, of the move- 
ments of the lungs, of the heart, or of the blood through the vessels; 
but under the influence of disease we become painfully sensible of 
several of these motions. Thus excessive sensibility is developed by 
inflammation, as shown in pleurisy, peritonitis, meningitis, &c, or by 
irritation of a mechanical or other nature, as evinced in colic, biliary 
and urinary calculi, gastralgia, and perforation of the stomach or in- 
testines, &c. It is very remarkable that pain, which is perhaps severer 
than any other, should arise so suddenly in parts which give no evi- 
dence of common feeling. Numerous other morbid sensations arise in 
connexion with nervous disorder of internal organs ; thus dyspeptic 
and hypochondriacal patients describe extraordinary feelings of heat, 
cold, weight, dragging, sinking, &c, in the abdomen, chest, and head, 
which seem to be the result of exalted and perverted nervous sensibility. 

136. In many instances we have to regard pain, merely as a symp- 
tom, which is only to be removed by means tending to remove the 
cause, that is the lesion which produces it (§ 132, 133 ;) but in many 
cases, on the other hand, pain, although a symptom, is an important 
element in the disease itself, and one against which remedies must be 
expressly directed. Thus it is, in neuralgia, gastralgia, nephralgia, 
colic, dysmenorrhoea, and perforated intestine. So long as the exces- 
sive pain lasts, all the functions suffer (§ 66,) faintness and exhaustion 
are apt to ensue, and if no relief comes, the prostration may be fatal. 
Here, to mitigate or remove the pain is a first and pressing indication. 
Again : in some other cases where the pain is less severe, it may be 
very hurtful by interfering with important functions. Thus the stitch 
of pleurisy impedes the breathing: the pain of tenesmus, and irritation 
of the stomach or windpipe, cause such distressing efforts at straining, 
vomiting, and coughing, that the vital functions are thereby kept in 
a state of disturbance, until the strength is exhausted. Here it is 



114 



ELEMENTARY NERVOUS FUNCTIONS. 



necessary promptly to direct the treatment towards the pain on account 
of its immediately pernicious effects. 

137. Remedial measures* — When excessive sensibility depends on 
inflammation, antiphlogistic measures will be those most calculated to 
remove it. Where it lingers after the inflammation, is more than it 
can account for, or is independent of it, then anodynes become the 
chief remedy. The most powerful of these is the vapour of chloroform 
or ether inhaled as above noticed (§ 128,) or externally applied : in either 
way it often serves for the mitigation or removal of local pain of a 
temporary character. If the case admit of the direct application of 
chloroform to the seat of pain, as when the skin or other superficial 
texture is affected, the chloroform may be applied on a piece of cotton 
or flannel covered by the hand, or by oil silk; or it may be rubbed in 
as a liniment mixed with an equal quantity of almond oil. Professor 
Simpson (to whom we owe the discovery of the anaesthetic power of 
chloroform) has recently found carbonic acid gas to be a very efficient 
local anodyne in cases of uterine neuralgia. He considers that the 
utility of the natural douches at Ems in painful uterine complaints may 
partly depend on the quantity of carbonic acid which they contain. 
The power of effervescing draughts and carbonated waters in relieving 
sickness may fairly be ascribed to this property of the gaseous acid ; 
which is probably also what reconciles the stomach to the copious 
draughts of many kinds of mineral waters which would scarcely be 
tolerable without it. Perhaps the soothing influences of the yeast 
poultice may be ascribed to the same ingredient. As carbonic acid 
gas is readily procured, its application deserves further trials. 

The most potent of the fixed anodynes are opium and its active prin- 
ciples; but these possess certain injurious influences (they arrest the 
secretions) (§ 70,) which sometimes render them less eligible than the 
weaker narcotics, hemlock, henbane, stramonium, belladonna, and In- 
dian hemp. The stronger preparations of aconite, and its alcaloicl, 
and tobacco, are powerful anodynes, and are very valuable as outward 
applications ; but their depressing operation on the heart renders them 
unsafe for internal exhibition unless under very careful superintendence. 
One of the most effectual methods with which I am acquainted, for re- 
lieving severe local pain, is the endermic application of morphia ; for 
this purpose a blister is applied to the painful part, and when it has 
fully risen, the cuticle is completely removed, and the denuded surface 
sprinkled with from half a grain to two grains of a soluble salt of mor- 
phia (the acetate or hydrochlorate) in fine powder; this may be repeated 
once or twice daily, according to the urgency of the pain. After the 
first irritation resulting from the application, the effect is anodyne, 
and then narcotic on the system, and less of the consequent injurious 
effects follows than when opiates are given by the mouth. The appli- 
cation loses all power, so soon as the blistered surface becomes dry. 
Counter-irritation and warmth also serve to relieve pain. The pain of 
gastrodynia may often be removed by applying a sinapism to the pit 
of the stomach — that of colic and dysmenorrhoea by hot fomentations, 
or bags of hot sand or salt, &c. Benumbing cold, produced by the ap- 
plication of a freezing mixture (pounded ice and salt) to painful parts 



LOCAL SENSIBILITY — VOLUNTARY MOTION. 



115 



is recommended by Dr. James Arnott as a very efficacious anaesthetic, 
and the plan seems to have answered in his hands; but great care 
should be taken lest the living structures and vital functions be injured 
through congestion or obstructed circulation induced by this means. 
In some cases, painful feelings are removed by making such pressure 
on the part as serves to counteract tension, and diminish, without 
stopping, the flow of blood through it. Painful affections occurring 
with a weak circulation, particularly if intermittent in their attacks, 
are often removed by tonics : thus neuralgia is successfully treated with 
quinine and iron, and hemicrania with quinine, bebeerine, or liquor 
arsenicalis. 

138. We are not possessed of equally efficacious means of restoring 
lost sensibility. Stimulant applications and frictions are serviceable 
where the defect arises from deficiency of circulation in the part; and 
tonics, especially of the chalybeate kind, are useful where there is an 
insufficient supply of good blood to the nervous centres and nerves. I 
have recently employed an acid phosphate of iron with advantage in 
such cases. Strychnia or cantharides given internally, and electricity 
used topically, may perhaps have some little effect in exciting the func- 
tions of the dormant nerves, but they certainly affect the motor func- 
tions more than the sensory. 



SECTION IV. 

DISEASED VOLUNTARY MOTION. 

139. The functions of certain portions of the nervous apparatus, by 
which they convey the impulses of the will to the voluntary muscles, 
may become disordered, and may so constitute an element of disease. 
Some of these disordered manifestations have already been noticed 
under the head of diseased irritability (§ 113 ;) and it was there ob- 
served that the fault is more commonly in the nervous influence which 
excites the muscles, than in the condition of the muscles themselves. 
This is the case in most convulsive diseases, and in those cases of pa- 
ralysis which depend on injuries of the voluntary nerves, or of those 
parts of the spinal and cerebral system which are the channels of voli- 
tion. A brief illustration of these affections may be given in a form 
corresponding with what has been said of the disorders of sensation. 
As in the case of diseased sensibility, so disordered motor power may 
depend on the condition of the nervous centres which originate that 
power, or on that of the nerve-trunks and branches which convey it 
to the muscles. The first class comprises disorders of centric or gene- 
ral volition ; the latter disorders of local manifestations of the power. 

DISEASES OF GENERAL OR CENTRIC VOLUNTARY POWER. 

140. The voluntary motor power may be said to be generally in ex- 
cess, when the brain is excited by strong emotions or feelings (§ 66,) 
by stimulating liquors (§ 56,) and by the hurried circulation of phrensy 



116 DISEASED VOLUNTARY MOTION. 

or phrenitic delirium. Hysteria, which constitutes in itself a micro- 
cosm of all the nervous disorders, furnishes analogous examples. The 
strength and rapidity of movement displayed in hysterical cases are 
sometimes astonishing ; yet such movements are obviously voluntary, for 
they are often performed rhythmically, or to a tune, as in dancing. The 
dancing of tarantulism, and the extravagant exertions of the fanatics 
called Jumpers, probably arise from erethism of the part of the nervous 
system concerned in the production of voluntary motion. A naturally 
high voluntary power, yet short of disease, is evinced in the energetic 
and active movements of persons, who excel and delight in feats of 
strength or agility. Mere muscular strength will not suffice without 
nervous energy to act on it. Most individuals, when in the vigour of 
health, are conscious of an energy, which at times prompts them to ac- 
tive exertion, and which is very like an overflow of voluntary motor 
power. A morbid excess of the same is commonly exhibited in those 
fidgety persons who are constantly in motion, and to whom a state of 
rest is almost an impossibility. 

141. Qeneral volition is more or less deficient in apoplectic coma, 
stupor from pressure, congestion, and other causes ; intoxication from 
opium, alcohol, and other narcotics, where other nervous properties are 
also impaired (§ 129 ;) in trance, catalepsy, and nightmare ; in a less de- 
gree also in cases of lethargy and of weakness from over-exertion (§ 68.) 
This defect may be sometimes suddenly induced by terror, surprise, &c. 
(§ 69,) which for a time take away the power of motion. Hence the fable 
of the power of the Gorgon's head ; and the signification of the expres- 
sions, petrified with astonishment, motionless with terror, fascinated, and 
the like. The muscular power (§ 110) is not lost in these cases, but 
only the influence of the mind over it — that is, volition. Slight de- 
grees of this lowered state of volition are instanced in those periods of 
languor which visit individuals suffering from indigestion, or during an 
oppressive condition of the atmosphere. Extreme weakness of a por- 
tion, or the whole, of the body is sometimes exhibited in a class of 
hysterical patients, in whom it is difficult to say whether the want of 
power, which approaches to paralysis, is in the muscles or in the volun- 
tary nerves. The powers of the voice and of the lower extremities are 
the most prone to fail, but there is commonly also great loss of vigour 
in other parts of the body ; and as the inability or indisposition to ex- 
ertion may last for months, or even for years, the muscles will waste 
for want of use unless their nutrition be promoted by electricity, fric- 
tion, and other like agencies that promote the circulation. The sudden 
loss, and as speedy recovery, of motor power, which has occurred in 
some of these cases, in some instances obviously from mental influence, 
inclines me to rank them among instances of defective volition. 

142. Examples of perverted voluntary power are afforded in chorea, 
delirium tremens, mercurial tremor, shaking palsy, and some analogous 
affections called hysterical. In these volition may also be defective 
(§ 141,) but it is not always so ; sometimes it is even more energetic than 
usual ; but each act of the will is perverted in its performance, and when 
it sets muscles in motion, they are the wrong muscles, or too many are 
moved, or too forcibly, or irregularly, so that the resulting action is 



VOLUNTARY MOTION — -DEFECTIVE — PERVERTED. 



117 



not in accordance with the will. This morbid state is also exemplified 
in the persons of many who are called nervous, and whose voluntary 
movements are performed with undue precipitation and trepidation. 
The pathological cause of these irregular excitements of the nerve- 
force, probably lies in the relations that connect the motor ganglia and 
nerves, and the blood which sustains their function and nutrition : a 
deficient supply and depraved quality of the blood especially induces 
the morbid excitement, instead of sustaining the normal function. 

PARTIALLY DISEASED VOLUNTARY POWER. 

143. We can scarcely point out examples of partial excess of volun- 
tary motion. The convulsive movements of voluntary muscles are quite 
involuntary actions, and have been already noticed under the head of 
diseased irritability (§ 113 ;) but it was there mentioned that they may 
arise from irritation of the nerves, independent of the influence of the 
will. Hysteria does, however, furnish examples of excessive move- 
ments of one limb, or part, of the body, so far amenable to mental in- 
fluence as to be excited and timed by ideas in the patient's mind. 
These cannot be said to be wholly involuntary ; but are the results of 
a wilful impulse, perhaps too strong to be easily resisted. Something 
bordering on the same thing is also exhibited in certain habitual move- 
ments or tricks to which some persons are addicted, and which, although 
really voluntary, become, through indulgence, spontaneous and con- 
stant, to the great annoyance both of performer and observers, and 
then require a great exertion of self-constraint for their control. 

144. Partial deficiency of voluntary motor power is very common, 
and, like local deficiency of sensibility, may be traced either to partial 
disease of the motor (anterior) columns of the medulla and their pro- 
longations ; — to disease of, or pressure on, a motor nerve in its course ; 
— or to a disordered condition of the ultimate distribution of the nerve, 
or of the circulation supporting its function. Thus paralysis of volun- 
tary motion in an extremity or a whole side (hemiplegia,) may arise 
from disease in the optic thalamus or corpus striatum of the opposite 
side : these being the channels of communication between the cortical 
seat of the sensorial functions and will, and the motory columns and 
nerves. Lesions of the motory (anterior) columns within the spine 
may intercept more or less the voluntary motor power of those parts 
supplied with spinal nerves from below the diseased point. Thus a 
lesion in the lower cervical portion may paralyze the upper and lower 
extremities and whole trunk, (except the diaphragm, which is supplied 
by the phrenic nerve :) but a lesion in the dorsal or lumbar portion 
paralyzes only the lower half of the body (paraplegia,) or lower ex- 
tremities. The mischief may, however, be more partial, paralyzing 
one nerve only, as, the portio dura, causing distortion of the features ; 
or the ninth nerve, causing difficult articulation, &c. The lesion of the 
nervous textures here alluded to may be structural change, such as 
tumours, effusions, or hemorrhage, or it may only be an altered state of 
the blood-vessels of the part. In all these instances either the struc- 
ture is injured, or the blood is prevented from duly supplying it with 
healthy nourishment. Another occasional cause of partial paralysis, 



118 



DISEASED VOLUNTARY MOTION. 



is the presence of poison in the blood or in the nervous tissue, as in 
the case of lead palsy. Severe cold, or continued pressure, will impair 
voluntary motor power in a limb, by checking the free flow of blood, 
which is essential to the maintenance of the proper function of the 
nerves as well as of the muscles. Hysteria affords numerous examples 
of impairment of volition in parts, as in loss of voice and power of 
articulation, retention of urine, paralysis of limbs, &c. ; these affec- 
tions often come on quite suddenly, and may as suddenly cease. 

145. Remedial measures. — Excessive voluntary power, as an ele- 
ment of disease, rarely calls for separate treatment. Where it occurs 
as a portion of the excitement of the nervous centres, it may be reduced 
by sedative influences of different kinds — depletion, antimonials, and 
cold to the head, being the most effectual where the excitement is at- 
tended with determination of blood; morphia, codeia, and other nar- 
cotics, where the excitement is more purely nervous. Inhalation of 
chloroform is as effectual in depressing the functions of the motor, as 
it is those of the sensory portion of the nervous system ; but as it has 
a tendency to cause some congestion in the nervous centres, it is not 
a safe measure when there is any sign of vascular fulness or excite- 
ment. 1 There are several milder narcotics which often prove useful 
in calming nervous excitement, and in tranquillizing the inordinate 
movements to which that leads- — such are henbane, lettuce, sumbul, 
camphor, and valerian. These are all very safe medicines, but apt to 
lose their powers very soon upon repetition. The violent exertions of 
maniacs are often wonderfully controlled by the application of the cold 
douche to the head, by the administration of nauseating doses of tar- 
tar emetic, and by the vertiginous effects of swinging. The vehement 
movements of persons affected by fanaticism and tarantulism commonly 
end in exhaustion ; they might probably soon be checked by a timely 
ducking with cold water, a remedy so often successful in hysteria. 

In all these different remedial measures, addressed to excessive mo- 
tor nerve-force, three modes of action may be traced: — 1. A sedative 
influence exercised on the circulation of blood which supplies the ner- 
vous centres or branches. — 2. A sedative influence exerted directly on 
the nervous functions. — 3. An indirect sedative influence coming in 
the form of exhaustion after continued excitement. The latter influence 
is mostly of use in preventing convulsive affections that result from 
superabundant motor power: habitual and regulated exercise proves 
efficient in this way, by expending the superfluous force. In fact, hys- 
terical convulsions of the ordinary kind seem to be a natural expedient 
for the discharge of pent-up accumulated force, and although they be- 
come injurious from frequent repetition, they are often productive of 
relief to the system at the time. 

146. The treatment of deficient voluntary power consists in means 
calculated to excite the nervous centres, either directly, or through the 
medium of the circulation. Agents which restore free circulation of 

1 I learn however from Professor Simpson that he has used chloroform inhalation for 
many hours in infantile convulsions, with no other than a composing effect. In one in- 
stance a child was kept more or less under the influence of chloroform for three days, to 
remove recurrent convulsions, and ultimately recovered. 



DEFICIENT — PERVERTED. 



119 



healthy blood through the nervous centres and the nerve-branches ge- 
nerally, increase voluntary power. Thus a stimulant draught raises 
the failing strength of a fainting person. By warmth and friction, one 
who is benumbed with cold recovers the use of his limbs. Sleep, or 
rest, restores voluntary power exhausted by fatigue. Sudden and 
powerful mental excitement, as from a fright, has been known to recall 
voluntary power which had long been lost. A lady who for several 
years had lost the use of her lower extremities, was startled by a rat 
running near her ; having an extreme antipathy to the animal, she made 
an effort, and sprang upon a table near ; the power, however, did not 
remain, for she could not get down again. More permanent cures of 
this kind have been effected by the excitement of religious fanaticism, 
as in the cases of the supposed miracles of Prince Hohenlohe, Miss 
Fancourt, &c. As we have seen that mental excitement sometimes 
causes excessive voluntary motion in healthy persons (§ 140,) so we 
perceive that, suddenly applied, it may restore the power of effecting 
it where this is deficient. Thus the dread of branding by a hot iron, 
of the application of a large blister, or even of a douche bath, has some- 
times cured hysterical palsy ; and a sudden emotion of surprise has been 
known to restore a lost voice. 

But in some cases volition is defective in consequence of pressure 
on, or congestion in, the brain, which then prevents the due motion of 
the blood through the organ, as in plethoric lethargy, or apoplectic 
coma : here depletion and derivation sometimes answer in restoring the 
power. There is also a form of palsy due to anaemia, or deficient sup- 
ply of blood to the nervous centres; this may be removed by an op- 
posite mode of treatment, comprising the administration of stimulants as 
temporary means of restoring the circulation, and of chalybeate tonics, 
which act more tardily, by augmenting red blood. In the lethargy of 
narcotism and asphyxia, volition is often restored by means which ex- 
cite strong sensations and reflex actions, such as dashing cold water 
on the face and chest, the application of ammonia or other stimulating 
vapours to the nostrils, electric shocks, tickling, stinging with nettles, 
&c, and although the influence of these is only temporary so long as 
the stupifying influence remains in the blood, it may nevertheless 
prove sufficient to prolong life until this influence can be got rid of 
by other means. The trance or coma of hysteria may often be re- 
moved by a turpentine injection, or croton oil purgative, which acts 
both as a revulsive to the vessels, and a stimulant to the nerves ; I 
have also found the same measures answer in the stupor of ansemia re- 
sulting from deficient action in the kidneys ; doubtless they effect the 
elimination of the excremental poison through the intestinal glands. 
Urea has been found in the intestinal discharges in cases of suppressed 
urine. 

Perverted volition requires different methods of treatment according 
to its precise nature ; the state in delirium tremens is best corrected 
by narcotics, especially opium; in chorea, by nervous tonics, especially 
iron and zinc. In delirium tremens there is much involuntary tremor 
and agitation, independently of all affection of volitional powers, but 
these are much increased whenever any attempt is made to perform 



120 



DISEASED VOLUNTARY MOTION. 



voluntary actions. Neuro-sedatives are best suited to the alleviation 
of this nervous excitement, as has been already explained (§ 56.) Such 
remedies, however, may fail until the blood is relieved of the irritating 
matter, the presence of which keeps up the morbid excitement. The 
same remark is applicable to many cases of chorea, which are not re- 
mediable by tonics, until after the administration of purgatives and 
other evacuants. The connexion of chorea with rheumatism has been 
frequently noticed, and I have found that such medicines as are useful 
in rheumatism (for instance iodide of potassium, colchicum, and aconite) 
promote the cure of chorea in a very marked degree. Its completion 
is, however, even then to be looked for from the salutary operation of 
tonic remedies which have a remarkable effect in steadying the nervous 
functions. Hence iron, quinine, and their combinations, are the re- 
medies from which the most lasting benefit is to be anticipated. 1 These 
tonics operate in various ways ; they enrich the blood, and equalize 
and sustain the circulation, thus conducing to support the nutrition 
and stability of the nervous structures. 

147. The treatment of locally diseased voluntary power should ge- 
nerally commence with attempts to remove the cause, which, however, 
is found to vary too much both in seat and nature, to admit of any 
precise enunciation of remedial measures. The treatment of defective 
voluntary power comprehends the complex subject of the management 
of paralysis, which commonly comprises means calculated to restore 
the circulation through the affected part of the nervous system to its 
proper state, and sometimes, also, the use of agents which stimulate the 
part, such as electricity, 2 rubefacient frictions, and blisters. Strych- 
nia and cantharicles, given internally, are supposed to have a directly 
stimulant action on the motory columns and nerves. 3 

3 Mercurial tremor affords another good illustration of the principles of treatment here 
laid down. Iron is its best antagonist, but the administration of this remedy is rarely 
effectual until the mercury has been, to a certain extent, eliminated from the system 
through the excretions, and in promoting this object the influence of iodide of potassium 
is invaluable. I believe the beneficial influence of many of the celebrated mineral waters 
to be connected with their combination of the eliminant with the tonic power. 

2 In the use of electricity as a means of restoring the lost power of a palsied nerve, it 
may be well to bear in mind the observation of Professor Matteucci (Lectures on Physical 
Phenomena, &c, p. 262,) that a direct current of electricity, from root to branches, ex- 
hausts nervous power: whereas an inverse current, from branches towards the nervous 
centre, causes an accumulation and increase of power where it has been previously ex- 
hausted. Now as the object in electrifying a paralyzed limb, is not only to develop 
nervous force where it is weak, but also to exercise it in producing the contraction (and 
thereby the nutrition) of the muscles, it would seem desirable to alternate the direction 
of the electric current, from inverse to direct, giving however a much greater amount of 
the former than of the latter. 

3 Phosphorus is a reputed restorer of nervous power, and from its admitted existence 
as a constituent of nerve matter, I have been induced to test its properties. I first 
administered it in doses of one-twentieth of a grain dissolved in a little oil. In a few 
days the feces became luminous in the dark, and in a few more days I was compelled to 
suspend the administration in consequence of supervention of jaundice. This happened 
in two cases (one, hemiplegia, and the other great nervous debility) and seems to me 
to demonstrate that phosphorus exerts some specific action on the liver, or its ducts. 
There was no improvement of nervous power. I have, however, given phosphate of iron, 
dissolved in an excess of phosphoric acid, with better effect. This is an agreeable as 
well as efficient, form of the medicine, but it must be recently prepared, as the insoluble 
phosphate is soon precipitated. 



EXCESSIVE EXCITOMOTION. 



121 



SECTION V. 

' DISEASES OF REFLECTED AND SYMPATHETIC NERVOUS INFLUENCE. 

148. The nervous power, by which various movements and processes 
connected with organic life are excited, may be disordered, and its al- 
terations thus become remarkable constituents in many diseases. The 
contractions of all the sphincters, — those of the oesophagus, the glottis, 
the iris, and the eyelid, and the regular action of the muscles of re- 
spiration, seem to be sustained, independently of the will, by a nervous 
influence conveyed first by afferent nerves from the several parts or 
surfaces to the spinal marrow, and reflected from it through the efferent 
nerves to the muscles connected with the parts. The full establishment 
of this important physiological principle we owe to Dr. Marshall Hall. 

149. Increase of this involuntary exeitomotory power is instanced 
in the spasm of the throat, and sometimes of the sphincters, which oc- 
curs in hydrophobia, tetanus, and some hysterical affections. The 
hurried respiration, convulsive cough, violent retching, and hiccup, 
which are occasionally presented in these and other nervous diseases, 
may also be in part traced to an undue influence of the exeitomotory 
nerves of organic life. These actions are sometimes excited by sensa- 
tions (§ 134,) as the breathing by feeling of want of breath, cough by 
tickling in the air-passages, retching by nausea, &c. ; but it is mainly 
where either there are no such sensations, or where these bear no due 
proportion to the violence of the excited actions, that we are warranted 
in the conclusion that the exeitomotory function is itself exalted. 

A similar exaltation of the exeitomotory function, independent of 
the influence of sensation and volition, is exemplified when the volun- 
tary muscles are deprived of sensation and voluntary motion by dis- 
ease in the brain itself, or by cutting off the communication between 
the brain and spinal cord, without extensively injuring the structure 
of the latter (§ 118.) Thus, in paraplegia from injury of the upper 
part of the spine, the exeitomotory power of the nerves of the lower 
extremities is exalted, and tickling, or mere touching the soles of the 
feet or legs, will produce convulsive motions, although all voluntary 
power and sensation be wholly lost. 1 This phenomenon is sometimes 
so readily produced as to be a cause of much disturbance to the pa- 
tient, the mere touch of the bedclothes exciting troublesome startings. 
The same thing occurs in hemiplegia, but less distinctly, as the cere- 
bral influence is rarely here so completely intercepted. I have known, 
however, the convulsive motions of a paralyzed limb to become so vio- 
lent in a hemiplegic patient, that it was necessary every night to fasten 
it down to the bedstead to enable the patient to get sleep. 

1 The same phenomenon is exhibited in a high degree in the decapitated frog, in which 
touching the surface excites convulsive movements. A still more interesting illustration 
sometimes occurs in animals or persons whose cerebral power (sensation and voluntary 
motion) is impaired by opium or other narcotics; spasms or convulsive actions of the 
muscles being induced by tickling or pinching the skin, which shows the excited state of 
the reflex or spinal function. 



122 



REFLECTED AND SYMPATHETIC NERVOUS INFLUENCE. 



An instance of involuntary excitement of the muscles occurs in the 
symptom commonly called "fidgets," which often arises from reflected 
irritation set up primarily in the lower part of the intestinal canal, or 
in the uterus: another is seen in the sudden retraction of the testicle 
by the contraction of the cremaster, in diseases of the kidneys, and 
other urinary organs, on touching the inner part of the thighs. 

150. Under this head we must also glance at convulsions, which, ac- 
cording to Dr. M. Hall's views, and consistently with the phenomena 
of disease, may be referred to an irritation of the true spinal system. 
This irritation may be centric, as seen in epileptic and apoplectic con- 
vulsions from disease in the head, and in those caused by loss of blood; 
in these cases, the spinal and prolonged medulla being in some pecu- 
liar state of irritation, the excitomotory influence radiates therefrom 
to the limbs and muscles generally. Or it may be eccentric, com- 
mencing with irritation of the extremities of some afferent nerve, which 
is then transferred to the spinal centre, and then again reflected thence 
generally or partially. Convulsions arising from teething, or uterine, 
intestinal, and renal irritation, are of this nature, and a slighter de- 
gree of the same state of things is exemplified in the rigour caused by 
the sudden impression of cold on the surface, or by passing a bougie 
into the urethra of a nervous person. The centric and eccentric causes 
of convulsions, however, often co-operate. The centric excitomotory 
power being exalted by various influences, its overflow or discharge 
does not take place until provoked by some occasional irritation trans- 
mitted from some nervous extremity. In this view the exalted excito- 
motory power is the predisposing, and the distant irritation the ex- 
citing cause, of the convulsion. 1 

151. Partial spasms caused by reflected irritation, are exemplified 
in cramp in the legs, excited by the presence of acrid matter in the 
colon, in diarrhoea, and cholera; spasm of the glottis from a bone stick- 
ing in the pharynx, &c. More familiar examples of the same class of 
reflected irritation are found in sneezing from irritation of the nares, 
winking from irritation of the conjunctiva, coughing from irritation of 
the glottis, retching from irritation of the fauces, efforts to evacuate 
the rectum and the bladder from irritation of these parts respectively. 
But it must not be forgotten that all these latter examples are connected 
with obvious sensations ; they imply increased excitomotory influence 
only in the cases in which the resulting action is out of proportion to 
the sensations. 

152. But some of the most remarkable instances of reflected irrita- 
tion are displayed by the altogether involuntary muscles, the heart, 
and the muscular fibres of the air-tubes and intestinal canal. Thus 
inordinate action of the heart (palpitation) is commonly caused by the 
presence of irritating matters in the stomach, intestines, kidneys, or 
other viscera (§ 51, 54 ;) nay, we shall hereafter find, that the heart is 

1 Some modern physiologists conceive that the sensory gang y ia are the primary seat of 
epilepsy, and that this is proved by the obliteration of consciousness, and the occurrence 
of clonic spasm, identical with that -which is produced by mechanically irritating these 
organs. Sometimes the irritation is propagated upwards, and cerebral disturbance 
results; at other times it is propagated downwards to the spinal chord, and then con- 
vulsive movements occur. 



CONVULSIONS — SPASMS. , 123 

liable to be excited by considerable irritation applied to any part of 
the body, as in fever and constitutional disorder. The spasm of the 
intestines, in colic, is induced by reflex irritation resulting from acrid 
matter in them ; for if it were from direct irritation alone, the spasm 
would only affect the part touched by the offending matter. 1 The 
spasm of the bronchi, so suddenly occurring in spasmodic asthma, also 
sometimes arises from intestinal irritation. It has long been supposed, 
and is still a common opinion, that these morbid sympathetic move- 
ments are due to the direct nervous connexion which the great sympa- 
thetic nerve establishes between the several organs ; but this supposi- 
tion assumes, what experiment has not proved, that the ganglia of this 
nerve are either centres of reflection, 2 or that they are sources of ner- 
vous influence, which is still more inconsistent with the latest researches. 
So far as we yet know, the spinal marrow is the centre of reflection in 
these, as in all the other, examples of reflex action that we have been 
considering, although the sympathetic nerves are the medium of har- 
monization. 3 

153. When phenomena of inordinate reflex action are general or 
extensive, as in convulsions, tetanus, and paraplegia, they must be re- 
ferred to an undue excitement or erethism of the spinal and prolonged 
medulla; but more partial phenomena may arise from similar excite- 
ment of a small portion of this organ alone, or of the incident (afferent) 
nerve of the part which occasions the phenomena, or of the excitomo- 
tory (efferent) nerve of the part which exhibits them. 

If we seek to know the causes of this excitement, we shall find that 
it is sometimes referable to an increased flow of blood through the 
spinal marrow or its nerves, or through the branches of the sympathe- 
tic nerve. Thus the early stage of inflammation of the spinal cord, or 
of its sheath, is attended with convulsions or tetanic spasm. It is 
very probable, that the spinal excitement (convulsions) occurring in 
epilepsy and apoplexy, is in part due to the flow of blood through the 
medulla being increased in proportion as that through the brain is im- 
peded : considerations based on ascertained causes of convulsive parox- 
ysms, and on the mode in which the encephalic arteries are distributed, 
countenance this supposition. 4 It appears, from an experiment of Sir 

1 Muller's Physiology (by Baly,) p. 737. 

2 It is now generally conceived that the special office of the sympathetic nerves is the 
production of an influence that harmonizes the chemico-vital processes of the system 
(nutrition, secretion, &c.) with themselves and with the operations of mind. — Carpenter's 
Human Physiology, 4th Edition, p. 864. 

3 Carpenter's Human Physiology, 4th Edition, p. 700. 

4 The explanation of epileptiform attacks, here proposed, deserves, at least, some con- 
sideration. It was first suggested to me by observing the symptoms of an epileptic patient 
who had a sort of tumour on the vertex (which proved to be of hydatid nature) projecting 
through an opening in the skull. As this tumour lay in contact with the brain, pressure 
could be communicated through it to this subjacent organ. A slight amount of pressure 
caused lethargy, or somnolency, in the patient ; a greater degree produced stupor and 
convulsions. Similar results have been obtained from experiments on animals. Slight 
pressure impairs, without arresting, the circulation through the cerebrum. The stronger 
pressure stops it altogether, and directs the current of blood which ought to pass there, 
upon the arteries of the cerebellum and spinal marrow; the functions of their ganglionic 
masses accordingly become proportionally excited. This then precisely corresponds with 
the phenomena of the epileptic fit. The slight attack [petit mal) consists simply of a tran- 
sient stupor passing, like a momentary cloud, over the sensorial powers. The severe fit 



124 REFLECTED AND SYMPATHETIC NERVOUS INFLUENCE. 



Astley Cooper's, as well as from the occasional occurrence of convul- 
sions during syncope, that an arrest of the arterial current sufficient to 
cause suspension of the cerebral functions, causes a momentary excite- 
ment of the medulla. In other cases, the excitement seems to be of 
even a more direct nature. Strychnia in a poisonous dose excites the 
medulla so speedily, (causing tetanic spasm,) that its effect can scarcely 
be due to increased flow of blood. This agent, indeed, seems to be 
electively attracted by the affinities of the spinal ganglia, as opium and 
alcohol are by the encephalic centres. So, too, we know, that me- 
chanical irritation of the spinal marrow or of its nerves will cause con- 
vulsive motions ; this is exemplified in the effect of tumours and spicula 
of bone in the spinal canal, in the head or in the course of nerves. But 
nothing exhibits this element of nervous irritation (apart, so far as is 
yet known, from vascular influence) so fearfully as traumatic tetanus. 
The irritation here begins in a distant nervous branch, and is propa- 

(grand mal) comprehends not merely suspension of sensorial and voluntary power, the 
function of the cerebral lobes and ganglia, but also excitement of the involuntary excito- 
motory functions of the cerebellum and medulla. But this diversion of the cerebral cir- 
culation may be produced by other means, besides pressure; there are various distur- 
bances of the quantity and motion of the encephalic blood that are capable of effecting 
it: thus convulsions with insensibility — i. e. medullary excitement with cerebral syncope 
— occur in consequence of extreme loss of blood, as well as in consequence of fulness; — 
in consequence of depraved quality, as well as of disordered quantity. It would far exceed 
the limits of a note to enter upon a detailed statement of cases illustrative of these views, 
but there is one natural provision concerned in the results that may be pointed out, 
namely, the greater proximity of the medulla and cerebellum to the source of arterial 
supply (especially through the vertebral arteries, which are least liable to derangement) 
so that under most circumstances of irregular flow of blood these organs get the first 
and best share, often at the expense of the cerebral hemispheres. This doubtless is a 
salutary arrangement to secure the maintenance of those functions that are most imme- 
diately important to life. Life may go on for some hours without the aid of the brain, but 
not even for a few minutes without the influence of the medulla, as this sustains the respi- 
ration. Sleep is a natural and prolonged condition like t\xv petit mal of epilepsy; the cere- 
bral power is impaired, whilst the energy of the medulla is enforced and augmented during 
its continuance. The close affinity between sleep and epilepsy is further shown by the 
way in which somnolency commonly follows the occurrence of epileptic attacks, and these 
frequently supervene during sleep. 

The following remarks comprise certain practical bearings of this subject, which my 
own experience has suggested: 

In a majority of instances convulsive fits of the epileptic or epileptoid character, have 
been immediately preceded by symptoms of disturbed circulation, such as palpitation or 
strong action of the heart, throbbing in the carotids, sudden change of colour and cold- 
ness of the extremities; these signs being sometimes obvious to others, when unobserved 
by . the patient. 

The fits may sometimes be prevented or arrested by the adoption of measures which 
tend to subdue disturbances in the circulation; as by making firm pressure on the ca- 
rotids (Dr. Parry,) dashing cold water on the face and neck, and plunging the hands and 
feet into hot water. 

The frequency of the fits is often reduced by remedies which equalize the circulation, 
either by reducing it where there is excitement or occasional palpitation, (hydrocyanic 
acid, digitalis, and aconite act in this way) or by raising its power when in a depressed 
state and irregular (iron, quinine, zinc, silver, and other tonics do this) or by purifying 
the blood when it is depraved (iodine and other eliminants possess this power.) 

The undue susceptibility of the nervous system itself in many such cases is of high 
importance; many of the remedial means alluded to above act mainly upon it as also do 
others which tend to improve the nutrition of the nervous structures. 

The more rational treatment of convulsive paroxysms (whether of the decidedly epi- 
leptic or mere hysterical class,) based upon these views, proves at least more successful 
than the too prevalent empirical plan of using first one remedy, and then another, re- 
puted to be specific, and in doses increased to a hazardous extent. 



DEFECTIVE KEFLEX ACTION — REMEDIES. 125 

gated to the medullary centre, the excito-motory function of which at 
length exhibits a state of erethism, which destroys life either directly 
by tonic spasm (§ 114) of the muscles of respiration, or by exhaustion. 
Tetanus may be defined to be dependent on an undue excitability of 
the entire series of the spinal ganglia. Slight impressions then pro- 
duce violent reflex actions ; when these are once established they are 
kept up by the irritation present in the spinal ganglia. Then the re- 
moval of any cause of nervous irritation fails to be of any service. In 
hydrophobia the irritation seems to be transmitted from the sensory 
ganglia or from the cerebrum — while in tetanus it issues directly from 
the spinal cord. 

Another cause which may be fairly assigned as sometimes increasing 
the involuntary excitomotory function, is accumulation by rest. The 
augmentation in narcotism from opium is of this nature, and also in 
injuries of the spine (§ 149,) which suspend the exhausting influence of 
volition on the whole or part of the marrow, so that the nervous energy 
accumulates therein, and becomes unusually abundant. There is a 
natural increase of excitomotory power in sleep, which by suspending 
the sensorial functions, augments the energy of those of the medulla ; 
but this accession of power, which then maintains the movements of 
respiration, also disposes to the occurrence of spasmodic attacks ; hence 
the fits of epilepsy and asthma commonly come on during sleep. So 
likewise sedentary habits, and too much indulgence in sleep, may cause 
an accumulation and morbid excess of involuntary nervous power, and 
develop convulsive and spasmodic symptoms, which are the result of 
its overflow. True coma differs from sleep mainly by the functions of 
the sensory ganglia being suspended or destroyed. In the slightest 
forms, as in hysterical coma, the cerebral functions are not abolished, 
but only much impaired, 

154. Deficiency of the reflex, or involuntary excitomotory function, 
is exemplified in forms of paralysis which affect the sphincters, the eye- 
lids, the muscles of respiration, and other parts whose normal action is 
sustained by these means (§ 148.) "When this function is generally 
and considerably impaired, the result is fatal, because respiration, deg- 
lutition, and other actions essential to life, are arrested. It is by 
interfering with these actions that apoplectic coma and narcotism de- 
stroy life ; and the state of sinking in excessive weakness or great de- 
pression, when the urine and feces are voided involuntarily, and the 
breathing is irregular and gasping, being forced by voluntary effort, 
further illustrates failure of the reflex power. From the same cause 
coughing and expectoration become inefficient in clearing the air pas- 
sages of mucus ; hence the bronchial and tracheal rattles which precede 
death. As these movements are the last to fail, so, in recovery from 
asphyxia, syncope, and other similar states of partially suspended ani- 
mation, the actions connected with the reflex function are the first to 
return with the restoration of life ; vomiting, coughing, and sneezing 
are among the early signs of reaction, under such circumstances. The 
steady tonicity of the muscles by which they are kept in their places 
when at rest is much under the influence of the spinal function ; hence 
when it fails an unsteady tremor affects the various muscles, which in- 



126 



REFLECTED AND SYMPATHETIC NERVOUS INFLUENCE. 



creases as strength declines. So also in the decline of life from age 
or extreme debility, the sphincters act imperfectly; incontinence of 
urine and feces, drivelling, lacrymation, and a sighing, moaning, or 
gasping breathing, betoken the failure of the nervous powers most 
intimately connected with the processes of life. 

A failure of the medullary function, similar in kind, but less in de- 
gree, is exhibited in all states of extreme debility, whether from exces- 
sive fatigue or excitement (§ 64, 65,) or from directly depressing or 
sedative influences, as in adynamic fevers (§ 105.) A person in this 
state is too weak to sleep ; for the medulla, partaking of the general 
exhaustion, cannot maintain the respiration without assistance from 
voluntary efforts. Hence a feeling of oppression and frequent sighing 
banish all repose ; or if sleep do occur, it is disturbed by the startings 
and fearful dreams occasioned by the painful sensations of imperfect 
breathing and the distressing efforts which they excite. 

155. Remedial measures. — As with other instances of exalted ner- 
vous function, so with excessive reflex action, when it depends on in- 
flammation, or determination or congestion of blood in the medulla, 
the most suitable remedies are such as are directed towards these states ; 
the same measures in less active degrees are also often useful in hys- 
terical affections, when these are accompanied by fulness of habit and 
spinal tenderness. But in my own experience cases of pure inflamma- 
tion of the medulla and its membranes, requiring active antiphlogistic 
treatment, are rare. Instances of a rheumatic kind where vascular 
excitement of the medulla is kept up by the irritation of morbid mat- 
ter in the blood, are far more common. Under such circumstances 
the most effectual remedies are agents which promote elimination, as 
for instance colchicum, iodide of potassium, guaiacum, and turpentine. 
In simple irritation of the nervous centres (as in tetanus, hydrophobia, 
poisoning with strychnia, &c.,) a narcotic or sedative which is able to 
lower the exalted function, is the influence that would seem to promise 
the best results. We possess some agents which efficiently reduce the 
energies of the spinal system, and cause general relaxation of the mus- 
cles; such are hydrocyanic acid, woorara, resinous extract of Indian 
hemp, codeia, belladonna, and conium : these drugs may themselves de- 
stroy life by arresting the function of the medulla oblongata, and 
through it respiration ; but this very action renders the remedies almost 
as dangerous as the disease. One of them, hydrocyanic acid, is also 
farther hazardous on account of the sedative influence which it exerts 
over the heart. Perhaps the least dangerous, and in this sense there- 
fore the safest medicines where full doses are required, are the extracts 
of belladonna and Indian hemp ; and these remedies have recently been 
successfully exhibited in cases of tetanus. The inhalation of chloro- 
form is also a powerful means for subduing this, as well as other forms 
of excited nervous functions, and although it can only be viewed in 
the light of a palliative in tetanus and hydrophobia, it has been of 
direct service in some of the less intense kinds of convulsive disorder. 
In the slighter irritations of the medulla, neuro-sedative medicines, 
given in moderate doses, often prove beneficial. Thus hydrocyanic 
acid is a very efficacious remedy in vomiting, nervous palpitation, and 



DEFECTIVE REFLEX ACTIONS — REMEDIES. 



127 



hiccup; it is likewise useful in convulsive cough, in which, however, as 
well as in spasmodic asthma, the extracts of belladonna and stramonium 
are still more effectual. The same medicines, and opium, are often 
beneficial in relieving the spasms of colic, dysentery, dysuria, and 
dysmenorrhoea. 

Some medicines, which act as stimulants to the heart and vessels, 
and to the cerebral functions, seem to operate as sedatives to the me- 
dullary system : such are the stimulant anti-spasmodics, ether, ammonia, 
musk, sumbul, essential oils, gum resins, creasote, chloroform, and al- 
cohol; these are useful remedies in spasmodic and convulsive affections 
in weak subjects without inflammation ; they probably operate by giving 
vigour and equable diffusion to the circulation, and by preventing 
undue local determination and congestion of blood in the nervous cen- 
tres. External heat and counter-irritation act in a similar way. 

There is another class of remedies w T hich have some power in re- 
ducing the excitability of the spinal excitomotory system — namely, 
tonics, especially those prepared from metals: but the operation of 
these is gradual, and therefore probably indirect. The sesquioxide, 
iodide, valerianate, and other preparations of iron are efficacious in 
chorea, and perhaps in the more chronic forms of tetanus. Nitrate 
and oxide of silver, valerianate, sulphate and oxide of zinc, sulphate 
and* ammoniuret of copper, and trisnitrate of bismuth, have been 
found to diminish the attacks of epilepsy, hysterical convulsions, spas- 
modic asthma and cough, gastralgia, dysentery, and other like affec- 
tions. The chief operation of these medicines is obviously on the vas- 
cular system, to which they prove astringent and tonic, but it is 
uncertain whether their beneficial action in nervous diseases is of this 
kind only, or whether they exercise any more direct influence on the 
nervous system besides equalizing the circulation. The same question 
is open with regard to certain regiminal means which are efficient in 
reducing nervous excitability, such as cold bathing, country air, change 
of air, and exercise. The latter, however, no doubt may prove useful 
by exhausting the superfluous nervous power (§ 153) through another 
channel, that namely of voluntary motion. 

The best remedies for defective or failing medullary function are 
stimulants, narcotics, and various strengthening measures. Fatal states 
of sinking have sometimes been removed by the free administration of 
ammonia, ether, brandy, and other stimulants ; the best proof of the 
beneficial operation of such agents is afforded when they procure re- 
freshing sleep, which in itself is a source of renewed power. Narco- 
tics also seem to be indicated, but in extreme conditions of weakness 
their indiscriminate employment is hazardous, as they may paralyze 
the little remaining power, and lull the patient into the sleep of death 
(§ 56, Note.) When given they should be preceded by, or combined 
with, stimulants ; and those narcotics should be selected which have 
the least depressing action, such as opium, ether, and henbane. Other 
means must, however, then be adopted to sustain the power restored 
by the stimulants, -especially the administration of nourishment fre- 
quently in a liquid form ; complete rest in a horizontal posture, and 
the exclusion of all exciting and exhausting influences; such as light 
and noise. 



128 REFLECTED AND SYMPATHETIC NERVOUS INFLUENCE. 



REFLECTED AND SYMPATHETIC SENSATIONS. 

156. Clinical observation teaches us that not merely motory impres- 
sions, but those also which cause sensations, may be reflected, so that 
when the impression is made on one part, the sensation is experienced 
in another. I do not allude to the fact that a stroke on the nervous 
trunk produces feelings referred to its branches, but I advert to im- 
pressions on the ultimate distribution of one nerve producing sensations 
in parts supplied by another nerve, or by another branch of the same 
nerve. The following are examples of this kind. Touching the ex- 
ternal auditory meatus causes a tickling sensation in the glottis. A 
calculus in the kidney sometimes gives rise to pain and numbness in 
the testicle and thigh ; one in the bladder produces pain referred to 
the extremity of the penis. Congestion of the ovaries and uterus 
causes pain in the back, loins, and thighs. Ascarides in the rectum 
induce itching of the anus, and of the pudenda in females. Congestion 
of the liver is sometimes accompanied by pain in the right shoulder- 
blade, and a disordered state of the stomach, occasionally with pain 
in the left shoulder-blade. In angina and gastrodynia the pain often 
extends to the whole chest ; and in the former especially, it radiates to 
the left arm. Severe frontal headache is almost instantly caused in 
some persons by acid ingesta, in others by eating ice. Irritation of 
the intestines, such as is experienced in cholera and colic, (especially 
painter's colic,) frequently causes pain and tenderness in the legs and 
feet, even when there has been no cramp or other excitomotory pheno- 
mena. Temporary neuralgic affections, generally described as spinal 
irritation and excessive cutaneous sensibility, seem to be due to similar 
causes. Instances of excessive sensibility often amounting to consi- 
derable pain, are very common, particularly in the female sex, and are 
occasionally very puzzling to the practitioner from their resemblance 
to inflammatory affections. They occur chiefly in nervous individuals 
(§ 126 ;) but not uncommonly in others not constitutionally nervous 
they form part of a temporary nervous susceptibility connected with 
weakness and inanition, after losses of blood and other exhausting in- 
fluences (§ 63, 64.) An example or two will suffice to show that they 
belong to the phenomena of reflex nervous action. A young female 
has an attack of tonsillitis — of pleurisy, of hepatic congestion, of gas- 
tric derangement, or of uterine irritation, — and after the symptoms of 
these affections have subsided, suffers pains of more or less intensity 
near the seat of the primary disorder, so as to give the appearance of 
a relapse. The wary physician remarks, however, that the pain is of 
a sharper and more shifting character; that there is a complete absence 
of such febrile and functional disturbance as real relapse would cause, 
and that there are peculiar nervous symptoms, especially extreme sensi- 
bility of skin traceable to a corresponding part of the spinal column 
behind, where on pressure there is tenderness, and sometimes radiation 
of pain to the seat of suffering in front of the body. The real truth is 
that the spinal irritability has been exalted by the primary disease, 
particularly in that portion which corresponds in position with the af- 
fected organ, and that this irritation is propagated to the sensory cen- 



SPINAL IRRITATION — CHOREA. 



129 



tres, and then reflected on the cutaneous and other nerves, occasioning 
in their extremities the abnormal sensations. v * Thus after tonsillitis, the 
morbid sensibility and tenderness is experienced close to the spines of 
the cervical vertebrae on the same side. After pleurisy, it is near the 
spines of the dorsal vertebrae ; after hepatic and gastric disorder, at 
those of the lower dorsal vertebrae ; and after uterine and gastric dis- 
order, along the lumbar and sacral portions of the spine, the pain then 
being very apt to be intense and to be extended over the loins, pelvis, 
and thighs. These are all so many several examples of what is com- 
monly called spinal irritation. 

In these and other analogous instances, the morbid sensations can- 
not be referred to direct nervous impressions, but to an influence pro- 
pagated from the spinal centre to the sensory ganglia, and then re- 
flected thence. 

Involuntary reflex actions issue from all the great centres of the 
nervous system — the spinal, the sensory, and the cerebral ganglia. 
The reflex actions determined by the sensory ganglia are instinctive, 
and in man these are masked by the superior cerebral influence and 
will ; but they are seen in full operation in morbid states where there 
is complete exhaustion and abeyance of cerebral power, as after re- 
peated attacks of mania or epilepsy, and also in instances of congenital 
idiotcy, where the cerebral influence has never been established. Cho- 
rea is something of this nature ; its seat is in the summit of the cranio- 
spinal axis. The fact that the symptoms cease during sleep is incon- 
sistent with the notion that it is the spinal centres that are solely or 
mainly involved. In chorea there is augmented activity of the sensory- 
motor centres, and diminution of the power of will. 

The sympathies subsisting between some organs are very remarkable ; 
this is especially the case with the breasts and the uterus. Applying 
the infant to the breast commonly induces uterine pains in women re- 
cently delivered ; the catamenial discharge has been induced in some 
instances by stimulating applications to the breasts. 

157. The remedies most effectual for the relief of reflected morbid 
sensations are — 1st, such as remove the irritating cause; and 2nd, 
such as deaden sensibility (§ 137.) The peculiar efficacy of trisnitrate 
of bismuth and hydrocyanic acid in relieving gastrodynia and some 
kinds of angina, is, however, not explicable through any narcotic 
quality; but is probably due to an influence exercised over the power 
of the nerves to transmit sympathetic irritations. These morbid sym- 
pathetic susceptibilities are often exalted, in common with other ner- 
vous functions (§ 126, 148) by weakness or irregularity of the circula- 
tion (§ 153;) and are generally diminished under a tonic plan of 
treatment, especially when the metallic tonics, preparations of iron, 
nitrate and oxide of silver, sulphate of copper, arsenic, &c, are used. 

The peculiar affection, alluded to above as spinal irritation, is no ex- 
ception to the applicability of this mode of treatment. In a few in- 
stances leeches or blisters to the tender part of the spine prove ser- 
viceable, but such means are rarely necessary, and prolonged or ex- 
cessive depletion and counter-irritation are positively injurious and 
tend to aggravate the evil. Anodyne applications to the spine, as of 
9 



130 



DISEASES OF SECRETION. 



chloroform, belladonna, aconite, arnica, and morphia, alternated by 
sponging with tepid or cold vinegar, or spirits and water, a tepid or 
cold douche, or dry cupping in the vicinity of the part, are more ef- 
fectual than weakening measures, and the permanent cure is most likely 
to be completed by a plan for invigorating and equalizing the circula- 
tion and nervous functions. 



SECTION VI. 
DISEASES OF SECRETION. 

158. The power of secretion appears to be a vital endowment of the 
ultimate cells or vesicles of secreting structures. 1 It is uncertain 
whether the process consists in the formation of the peculiar matter of 
the secretion, or merely in its separation from the blood. In the case 
of the urine and bile, these principles seem really to be formed in the 
blood without the aid of the secreting organs ; for urea has been found 
in the blood of animals whose kidneys have been prevented from acting 
by ligature of their blood-vessels, or by extirpation; and both urea and 
some of the principles of the bile (colouring matter and cholesterine) 
are found in the blood and in various parts of the body when the kid- 
neys and the liver respectively have been disabled by disease. But 
whether the secreting structures assist in the formation of the secre- 
tions, or only effect their separation, their elective power is equally a 
peculiar attribute of life, and inexplicable at present by any physical 
or chemical law. Thirty years ago 2 I advocated the opinion more re- 
cently advanced by Dumas and Liebig, that the formation of the prin- 
ciples of the chief secretions takes place through chemical affinities, 
(especially those of the absorbed oxygen and the constituents of the 
blood.) controlled by vital agencies; still in this view the power by 
which the liver separates bile; the kidneys, urine; mucous membranes, 
mucus, &c, is to be regarded as a vital property. 

We are then led to consider secretion as a peculiar property of the 
secernent structures, just as much as we do irritability, of muscular 
fibre (§ 110 ;) and as such, disorder of secreting power constitutes a 
primary element of disease. In doing this we avoid the hypothesis of 
some physiologists, who ascribe secretion to nervous influence, which is 
a notion by no means in accordance with numerous ascertained facts. 

159. In reviewing the other disorders of vital structures, we have 
found that many are plainly referable to changes in the supply of blood 
to the respective textures (113, 12T, 131, 133, &c.) The same in- 
fluence operates still more decidedly in producing variations in the 
process of secretion. The blood being the material from which secreted 
matter is supplied, modifications in its quantity or quality surely af- 

# J Muller De Glandularnm penitiori structura, Henle, AUgemeine Anatomie. Goodsir, 
Trans. Royal Society of Edinburgh, 1842. Bowman, Phil. Trans. 1842. 

2 In a thesis, De sanguine ejusque mutationibus, Edin. 1824. See also Med. Gaz. Sep- 
tember and October, 1835. 



EXCESSIVE SECRETIOX OF BILE. 



131 



feet the quantity or quality of this product. Thus when an increased 
flow of blood takes place to a mucous membrane, its secretion is in- 
creased, and sometimes rendered more acrid than usual; but a con- 
gested state of the same membrane rather impairs the secretion. The 
most common causes of altered secretion are such as operate on and 
through the sanguiferous system. 

160. But affections of the nervous system, and of the mind which 
acts through that system, also influence the secreting process ; this is 
shown by the mouth watering at the sight, or thought, of a good meal ; 
by the bilious diarrhoea that mental agitation causes in some persons ; 
the large flow of limpid urine after nervous agitation ; the tears excited 
by grief or other strong emotion ; and the unwholesome quality of a 
nurse's milk when she is in a state of anxiety or apprehension. We 
do not however know whether these influences act by altering the flow 
of blood (§ 159,) or, in a more direct way, by modifying the vital pro- 
perties of the secreting organ (§ 158.) 

161. The importance of this element of disease may be estimated by 
the universality of the process of secretion, which includes both the 
formation of excrementitious products (only to be voided out of the 
system) and recrementitioiis products, (concerned in effecting digestion, 
assimilation, and nutrition,) and also by the extent of its effects, in re- 
lation both to the destination of the secretion, and to the condition of 
the blood from which it is separated. The several processes of secre- 
tion may be influential in producing diseases through being either ex- 
cessive, deeicient, or of a perverted kind. 

162. Excessive secretiox of any kind, whether of bile, urine, mu- 
cus, or anything else, may weaken by the drain which it causes from 
the mass of blood (§ 28, 71 ;) and the debilitating effect is in proportion 
to the quantity of the loss, and to the amount of the animal matter 
which is contained in the secretion. Thus an excessive secretion of 
bile weakens more than that of thin mucus. But each secretion has 
also peculiar effects which are connected with its office and composition ; 
and these effects may tell forwards, on the parts to which the secretion 
goes, and backwards, on the secreting organ and on the blood from 
which the secretion is formed. 

163. The forward effects of an excessive secretion of bile depend on 
its stimulating properties. It irritates the intestinal tube, causing 
bilious diarrhoea or cholera. The symptoms of this disorder consist 
in an exaggeration of such properties of the alimentary canal as have 
already been spoken of as elements of disease. Thus the irritating 
bile causes increased irritability (§ 113,) and more rapid motion of the 
contained matter through the intestinal tube ; pain from exalted sensi- 
bility (§ 131, 135;) vomiting, straining, and cramps, from exalted ex- 
citomotory function (§ 149, 151 ;) and profuse mucous secretion from 
excited secernent function (§ 162.) An excessive secretion of mucus 
into the intestines may cause only simple diarrhoea; but if it be into 
the bronchi it may occasion dyspnoea and cough, and, if not expecto- 
rated, even suffocation. Excessive secretion may in the stomach cause 
pyrosis or waterbrash, the liquid being sometimes acrid, and also 
nausea and vomiting, as well as eructation. The excessive discharges 
from secreting organs generally constitute fluxes or profiuvia; and 



,132 



DISEASES OF SECRETION. 



those from internal enclosed serous surfaces, or cellular texture, con- 
stitute dropsies. The effects produced vary according to the situation. 

164. But excessive secretion also acts backwards, on the secreting 
organs, and on the blood from which it proceeds. It often weakens 
the vital powers of the organ, so that it subsequently becomes torpid 
so far as its proper function is concerned. Thus after diarrhoea the 
bowels often become confined, with defective secretion. So, too, in 
cases where an excessive secretion continues for a long time, it gene- 
rally becomes impaired in its quality, because the secerning organ is 
weakened and rendered unable to perform its proper office. 

165. Excessive secretions, if rich in animal matter, not only reduce 
the mass of the blood, but often also affect its composition. Thus bile 
and urine, which differ much in composition from the blood, if separated 
in unusual amounts, must leave that fluid changed. Urine contains 
a large proportion of azote ; its excessive separation from the blood 
therefore leaves a comparative predominance of hydrogen and carbon 
in this fluid. The bile, again, abounds in hydrocarbon, and its copious 
removal accordingly leaves a superfluity of azote. It may be objected 
to this statement, that some chemists are of opinion that the urine and 
the bile are not formed from the constant elements of the blood, but 
from materials derived directly from the food, and from the decay or 
transformation of the tissues. To this it may be replied, that this 
opinion is not at present more than hypothetical ; and should it ulti- 
mately prove to be true, it would hardly affect the question, with the 
undoubted fact before us that the secretions of the liver and of the 
kidneys are balanced one against another, and also adjusted to the 
removal of carbon by the lungs ; whether the materials by which these 
eliminating processes are supplied by the principles of the blood itself, 
or the decayed constituents of tissues, or matters derived from the 
food, the co-operation of all is equally required to maintain uniformity 
in the composition of the circulating fluid ; if one of these processes is 
more active than the others, the blood must suffer from the excess of 
such matters as the less active processes allow to accumulate in it (§ 68, 
69.) A practical illustration of this position is offered in the case of 
bilious diarrhoea or cholera. These fluxes of bile are either accompa- 
nied by a highly loaded state of the urine, or by fever; in the latter 
case, the fever does not subside until the urine becomes very copious, 
or deposits an abundant sediment. The most probable interpretation 
of this fact is, that the excessive secretion of bile disorders the com- 
position of the blood: so long as the kidneys rectify this disorder by 
separating in greater abundance the solid contents of the urine, no 
fever results ; but if the kidneys fail in their task, fever ensues, and 
continues until they resume it; then a free secretion from them and 
copious uninary deposit becomes symptomatic of the decline of the 
fever. 1 

1 Note by Dr. Mann. — In order to estimate the influence which disordered secretion 
may have in the constitution and aggravation of disease, it may be useful to glance at 
some of the more recent conclusions of physiologists respecting the chief secretions. 

The entire action of the liver in the animal economy has not been yet satisfactorily 
determined, but all physiologists now seem to be pretty well agreed that at any rate it 
removes from the blood those hydro-carbonaceous products of the destruction of tissues, 



EXCESSIVE SECRETION — REMEDIES. 



133 



166. The remedial measures that are serviceable in cases of exces- 
sive secretion well illustrate the view that has just been given of the 
balancing office the secretions are designed to fulfil. In so far as ex- 
cessive secretion is dependent on the quantity and quality of the blood 
(§ 159,) the treatment should be addressed to this fluid: it maybe 
attacked by depletion, derivation, and evacuation, in cases of conges- 
tion or determination of blood; and in such cases the excessive secre- 
tion itself should not be hastily checked, as it may be a natural means 
of relief ; nay, in some cases, it may even be most speedily arrested 
by means which for the time increase it: thus a large dose of calomel 
will sometimes, after first purging, stop a bilious diarrhoea connected 
with an engorged liver, which astringents fail to check. But where the 
excessive secretion proceeds more from nervous and other sources of irri- 
tation (§ 160,) and causes weakness and disturbance of the functions, 
it is more important to check it at once. Secretions are diminished 
by influences which act as general tonics or astringents (§ 124,) and 
by others which operate only on particular organs. Of the former 
class of agents are, cold applied to the part, common astringents, such 
as alum, superacetate of lead, sulphates of zinc and copper, gallic and 
tannic acids, and substances which contain them, as nutgalls, oak bark, 

that cannot be converted into simple sugar and fat, and that it does this by changing 
them into glyco-cholic and tauro-cholic acids, which perform a certain definite office in 
the digestive process, and are then carried otF from the lungs as carbonic acid and water, 
their sulphur and alkaline bases being thrown into the urine. But it is also now clear, 
that both the liver and kidnej^s eliminate superfluous alimentary matters, as well as the 
products of disintegration of the organs. The liver turns all forms of saccharine matter 
contributed by the food into liver-sugar, and all kinds of fat from the same into liver-fat; 
and also makes the same substances out of protein compounds. Liver-sugar and liver-fat 
seem to be in a peculiarly favourable state for undergoing the process of further oxidation 
and decomposition. M. Bernard's experiments seem to point out that the liver also 
exercises a subsidiary assimilative action, beyond its excernent one, by rendering albumen 
more fit to be carried through the channels of the circulation and even by forming 
fibrin out of its material. The principal purpose performed by the urine is unques- 
tionably the removal from the blood of worn-out azotized matters that have done their 
work. The urine of children contains a larger proportional amount of urea compounds 
than that of adults, because the processes of disintegration are going on very actively in 
their bodies. The quantity of urea and sulphates in the urine is augmented by muscular 
exertion. But on the other hand the amount of alkaline phosphate is increased by mental 
exercise, the phosphorus proceeding from the disintegration of nervous substance. In 
inflammatory disorders of the brain, where the disintegration of its texture is accelerated, 
the phosphates of the urine always become abundant. The kidneys, however, not only 
carry off the effete azotized matters, phosphates, and superfluous water, but they also 
receive many other foreign matters that may be introduced from without in hurtful 
quantities, and it is remarkable that these are removed more readily whenever the kid- 
neys are stimulated to increased action. Wohler has shown that those soluble salts are 
most readily got rid of out of the system that most easily determine the blood towards 
the kidney. The effete organic matters, on the other hand, cannot be removed by the 
same means as readily, for Professor Krahmer has shown that when they are in excess 
in the blood, diuretics rather produce irritation and congestion of the kidneys, with sus- 
pended action, 1 than increased action. The alkalies, their carbonates and vegetable 
acid salts, however, seem to augment the quantity of organic matter in the urine, as well 
as of inorganic salts. 2 

Recent researches have further proved that common salt increases the amount of urea 
(Bischoff,) and liquor potassse has the same effect, and further remarkably augments the 
excretion of sulphuric acid in the urine (Parkes.) 



1 Hellor's Archiv. Dec, 1847. 

2 Golding Bird in Med. Gazette, 1848. Vol. xlii., p. 230. 



134 



DISEASES OF SECRETION. 



rhatany root, catechu, matico, and mineral acids, &c. These act mo$t 
surely when directly applied, as instanced by their use in diarrhoea 
and leucorrhoea ; but they seem to have some effect also through the 
medium of the circulation, for when taken internally they reduce the 
secretions of the air passages and skin. Of the agents which more 
specifically diminish the secretion of particular organs, without exer- 
cising any general astringent effect, may be mentioned opium, which 
remarkably lessens the secretions of the liver and intestines, and some- 
times that of the kidneys too. 

If an excessive secretion have already caused febrile disturbance, 
great advantage will be found to result from the use of measures which 
increase other secretions, and in this way the balance of the normal 
condition of the blood is restored, as before explained (§ 165.) It is 
thus that saline diuretics and diaphoretics are highly serviceable in 
bilious cholera. In renal irritation with copious secretion of lithic 
acid, blue pill, which augments the secretion of bile, is often beneficial. 
These means may be supposed to operate partly as derivants; but the 
manner in which they remove the febrile irritation, after the reduction 
of the excessive secretion, renders it most probable that they act also 
by removing from the blood dregs left by the inordinate separation of 
the matter of the single secretion which has been in excess (§ 165.) 
No practical physician can doubt that we possess medicines which 
often augment the secretions of particular organs (mercury that of the 
liver and salivary glands, colchicum that of the kidneys, &c.,) but 
there is a limit to the operation of these agents ; the limit may how- 
ever be extended by simultaneously acting on other organs which 
maintain the balance. Hence in any disturbance of the secretions, 
especially if it continue long, combinations of medicines are much 
more useful than the administration of such as fulfil one indication 
only; thus experience has sanctioned the practice of conjoining mer- 
curials with diuretics, and antimonials with salines, &c. 

167. Secretions may become deficient in consequence of a weakened 
state of the whole circulation, or of that of the secreting organ, as in 
the case of exhaustion from previous excitement (§ 164.) They may 
be diminished by depressing influences which paralyze generally the 
vital powers, as seen in the operation of zymotic and narcotic poisons 
(§ 56, 64, 65.) Or they may be checked by agents like cold and 
astringents, which increase the tonic contraction of the vessels of the 
part (§ 77,) or by those which influence the whole sanguiferous system, 
as is the case in the hot stage of fevers (§ 85, 421.) 

Deficient secretion of any natural or habitual discharge (§ 70) may 
cause a fulness of the blood-vessels ; general, if the secretion be na- 
turally copious ; local, if it be trifling in quantity. Thus deficient se- 
cretion of urine or bile may lead to general plethora, or to extensive 
local congestions, which may end in dropsical effusions, fluxes, hemor- 
rhages, or inflammations. Diminished secretion of tears or saliva 
merely causes fulness and dryness of the parts immediately concerned. 

The morbid effects of deficiency of secretion may be excited both 
forwards, that is on the parts for which the secretion is destined, and 



DEFICIENT SECRETION — EFFECTS. 



135 



backwards, that is on the organ by which, and on the blood from which, 
it should be eliminated (§ 162.) 

168. Deficient secretion of bile causes disorder in the latter stages 
of digestion. The neutralization of the acid in the chyme, and the 
separation of the chyle, to which the bile seems to contribute, are im- 
perfectly performed, and sometimes colic and diarrhoea, sometimes cos- 
tiveness, result. Deficient secretion of mucus in the intestinal canal 
and bladder exposes their lining membranes to suffer more irritation 
from the matters that are habitually in contact with them. Deficient 
secretion of mucus on the respiratory membrane may lessen the faci- 
lity with which the air and blood act on each other. Insufficient se- 
cretion of cerumen in the ear, or of saliva in the mouth, impairs re- 
spectively the faculty of hearing, and the process of mastication. A 
want of synovia in the joints has been supposed to be the cause of im- 
perfect motion and subsequent inflammation of their structures. 

169. The effect of deficient secretion in causing congestion of the 
organ concerned, has been already noticed: the concomitance of con- 
gestion and defective secretion, in the case of the liver, the kidneys, 
and mucous membranes, is well known ; but either may stand in the 
position of cause or effect, for circumstances which increase the secre- 
tion diminish the congestion, and influences which reduce the conges- 
tion tend to restore the secretion. 

170. The most remarkable of the backward effects of deficient se- 
cretion are instanced in cases of the excretions (§ 70.) The materials 
of urine and bile appear to be positively noxious, and to poison the 
system if not separated from the blood. Hence the sudden suppres- 
sion of urine or bile causes typhoid symptoms, extreme depression 
and coma, which may speedily end in death; and in such cases, urea, 
or the colouring matter of the bile, has been found in the blood and 
in various organs. Where the suppression is incomplete, the poison- 
ing process more tardy, various functional and visceral derangements 
are produced, such as delirium or lethargy, convulsions, dyspnoea, pal- 
pitation, vomiting, diarrhoea, dropsical effusions, and structural de- 
generations. But the amount of these effects will depend on the extent, 
and especially on the suddenness, of the diminution of the excretion ; 
and it is very remarkable, when it is very gradual, how little disturb- 
ance it may for some time induce. In these gradual cases, excre- 
mentitious matters may be detected in the blood, and in other fluids 
and solids of the body, more certainly and decidedly than when the 
suppression is sudden. Thus in some structural diseases of the liver ? 
the colour of the bile becomes manifest first in a yellow, and then from 
accumulation, in a deep greenish colour in all the textures, consti- 
tuting the yellow and the black jaundice. In cases of extensive granu^ 
lar degeneration of the kidneys, in which scarcely any urea is excreted 
by these glands, this principle is found in the blood and various fluids 
of the body. In the case of a patient of mine affected with ascites 
from disease of the heart, liver, and kidneys, Dr. Garrod obtained 
nearly four grains of nitrate of urea from an ounce of the peritoneal 
fluid, and a considerable quantity of bright yellow solid matter, pro- 
bably bilious. In other cases I have known the fluid of ascites and 
anasarca, induced by diseased kidneys, to emit a decidedly urinous 



136 



DISEASES OF SECRETION. 



smell, and to exhibit on analysis easily appreciable quantities of urea. 
One of my pupils, Mr. Edward Palmer, detected urea in the serum 
contained in the ventricles of the brain, in a case of fatal apoplexy 
connected with granular kidneys and diseased heart. 

The inequality observed in different cases with regard to the pro- 
duction of symptoms from uraemia (urea in the blood) has led many to 
question the power of urea to cause the symptoms ascribed to it (coma, 
convulsions, &c. ;) and it is said that urea has been artificially intro- 
duced into the blood of living animals without any morbid effects en- 
suing. Professor Frerichs, of Kiel, suggests the hypothesis that the 
poisonous properties of urea in the blood depend on its conversion into 
carbonate of ammonia through the agency of some ferment. If the 
urea be abundant, and the conversion into carbonate of ammonia be 
sudden, coma or apoplexy is the result: if more slow, the symptoms 
are those of stupor, prostration, and convulsions. In support of this 
notion, Dr. Frerichs states that he has detected carbonate of ammonia 
in the breath during ursemic intoxication; and he has succeeded in 
causing similar symptoms by injecting a solution of carbonate of am- 
monia into the blood-vessels. 

The clinical history of disease abundantly illustrates the resources 
which nature brings into play to relieve herself from the mischief de- 
pendent upon failure of any of the great eliminating organs. Other 
portions of the excretory apparatus then throw off the offending mat- 
ters. Thus when the action of the liver is obstructed, the urine mani- 
fests at first an increase of its ordinary pigmentary principle, and 
afterwards the presence of a new matter of the nature of purpurine or 
purpurate of ammonia, a highly carbonized body. If the elimination 
of the bile be farther impeded, the true bile pigment presents itself in 
the urine, this secretion then becoming of a dark orange, or olive 
green colour. Such vicarious action of the kidneys must be viewed in 
the light of relief designed for the service of the general system. I 
have known cases of jaundice in which the redundancy of bile material 
was thus disposed of during several months, without such rapid failure 
of health being induced as might have been anticipated under the cir- 
cumstances. In cases of Bright's disease where there have been ur- 
gent symptoms of poisoned blood at first, these are alleviated under 
the operation of purgative medicines ; a portion of the urea, and other 
urinary constituents being removed through the intestinal surface ; these 
principles indeed may be detected in the secretions of the intestines. 
These facts serve, not only to explain why the diminution of an excre- 
tion is less injurious when it takes place so gradually that there is time 
for a compensatory operation to be established, but also to point out 
an important therapeutical means whereby such a result may be hastened 
or brought about. 

The glandular apparatus of the intestines are important excretory 
organs whose main specific function seems to be the removal of putrid 
and otherwise offensive matters from the system. Hence when from 
extreme weakness and failure of the vital powers, from imperfect nu- 
trition, or from the presence of a septic and poisonous ferment in the 
body, the normal process of decay and decomposition is quickened. 



DEFICIENT SECRETION — REMEDIES. 



137 



the alvine excretions become excessively fetid, and the worst results 
may follow if they are locked in or suppressed under such circumstances. 
In low or typhoid fevers, great relief often ensues upon the occurrence 
of fetid diarrhoea. Suppression of the catamenia also induces disorder 
not only through the production of a state of plethora, but also by 
rendering the blood depraved ; this follows as a natural consequence 
from the fact that the catamenial discharge contains matter of an ex- 
crementitious nature. 

171. The excretions are deficient in most idiopathic and symptoma- 
tic fevers ; and there can be little doubt that many of the constitutional 
effects of such fevers are in great measure due to this important fact. 
The positively noxious properties which excrementitious matter retained 
in the blood is known to possess (§ 170,) must be taken into account 
when we attempt to explain the states of constitutional irritation and 
depression, and perversion of functions, which fevers so generally pre- 
sent. The morbid conditions of the blood, manifested in some such 
cases in its fluidity and in petechial appearances of the skin, may also 
be in part referred to defective elimination of effete matter; 1 and it is 
when the secreting organs recover their power, and a diarrhoea occurs, 
or a copious discharge of highly loaded urine, that these appearances 
cease. It is very probable that severe mechanical injuries or shocks 
(§ 52,) and animal and other poisons (§ 85, 105, 57, &c.,) sometimes 
operate by thus injuring the vital powers through which the blood is 
continually purified from its own noxious products ; and that this is one 
of their modes of action seems almost certain from their effect in sup- 
pressing or impairing the natural excretions. Accordingly, in such 
cases, urea has sometimes been detected in the blood. 

There can be little doubt that a morbid element, which in its ex- 
tremes acts so injuriously as to cause serious disorder, and even speedy 
death, must in slighter degrees be still an important cause and con- 
stituent of disease ; and I believe that gout, rheumatism, and many 
cachectic states leading to diseases of nutrition, degenerations, dropsies, 
&c, are essentially connected with defective excretion. It is a com- 
mon observation of gouty patients that their urine is either more scanty 
or paler than usual before a paroxysm, and they hail the appearance 
of a red deposit in the secretion as an indication of the departure of 
the enemy. Dr. Garrod remarks that before the gouty fit, and at its 
commencement, there is a disappearance of lithic acid from the urine, 
and an increase of it in the^ blood; and that the converse takes place 
as the attack declines. 

172. Remedial measures. — Deficient secretion may be caused by 
deficient or excessive supply of blood to the part, as in various cases 
of anemia, congestion, and inflammation (§ 159.) It must therefore 
be treated by the remedies adapted to the precise condition present: 
thus stimulants restore secretions that are scanty in consequence of a 
defective supply of blood ; but depletion and derivation may be the 
best remedial measures, when they are stopped by inflammation and 
congestion. 

1 Purpura I have found to be often connected with, hepatic congestion and imperfect 
excretion of bile ; it is most effectually removed by remedies which promote the restora- 
tion of the proper secretion. 



138 



DISEASES OF SECRETION. 



173. But sometimes the first disorder is in the secreting structure 
itself (§ 158,) and may best be removed by agents which specially in- 
crease the respective secretions, as common stimulants will not do. 
Thus mercury increases the secretion of the liver; colchicum, nitre, 
and other salts, with other diuretics, that of the kidneys; crotc-n oil, 
jalap, sulphate of magnesia, and other purgatives, that of the intes- 
tines ; and this they do, however introduced into the system, whether 
by the mouth, through the skin, or by injection into the vessels or 
textures. These are important practical facts, however difficult they 
may be to explain ; and their application to the restoration of defective 
secretions is sufficiently obvious. 

174. But these specific stimuli of the secreting organs (§ 173,) if 
used in excess, or too long, may not only cause general weakness, but 
also may exhaust even the vital powers which they first excite (§ 159:) 
and the result may be either a diminution of the secreted fluid, or of 
its most characteristic constituents. Hence the long or excessive use 
of mercury causes torpidity of the liver ; that of purgatives, the im- 
perfect action of the bowels ; of diuretics, scanty, albuminous, or watery 
urine, defective in urea. These facts point out the expediency of in- 
termitting the use of such agents, and of alternating them with others 
calculated to improve the vital properties of the textures generally, or 
of employing the two classes of remedies conjointly. Tonic medicines, 
and such regiminal means as improve and equalize the state of the cir- 
culation (§ 124,) and keep the digestive and assimilative functions in 
the best order, so improving the condition of the blood, are well cal- 
culated for this purpose. In illustration of the position, I may refer 
to the acknowledged advantage of giving bitters with or after mercu- 
rial courses ; chalybeates with or after saline aperients and diuretics, 
when these are long used : such tonics, if used alone, or at first, check 
the secretion desired to be increased, but when subsequently added, 
they sustain it and render it permanent. Some medicines which are 
generally of inferior efficacy to those already named, are nevertheless 
better suited to improve deficient secretion in some chronic cases, be- 
cause they are less exhausting, and combine some measure of tonic in- 
fluence with the power of increasing the secretions. Taraxacum, pre- 
parations of iodine, sarsaparilla, and the nitric and nitro-muriatic acids 
may be named as illustrations of such agents. Courses of these medi- 
cines are sometimes very efficacious in keeping free the secretions after 
they have been restored by more powerful means (§ 173 ;) and they 
likewise often improve the functions of digestion and nutrition. The 
salutary operation of many kinds of mineral water is dependent upon 
a similar principle. Saline chalybeates exercise the two-fold function 
of increasing the secretions, and conferring tone upon the general sys- 
tem ; and they do this with the production of less disturbance than 
most medicines which act in the same way. 

175. Where deficient secretions are not readily restored, the fortvard 
disorder (§ 168) arising from their deficiency may be sometimes tem- 
porarily obviated by artificial substitutes. Thus in defective secretion 
of bile, the action of the intestines may be promoted by the exhibition 
of ox gall. A combination of aloes and soap has been thought to sup- 



PERVERTED SECRETION — EXAMPLES. 



139 



ply the place of bile in some cases. Toasted bacon at breakfast bears 
a similar reputation ; but it is probable that it really excites the liver 
to increased secretion, as other fat matters do: cod liver oil seems to 
act upon the bowels by means of the bile which it contains. Imperfect 
lubrication of the throat and larynx, and other mucous membranes, in 
consequence of deficiency of mucus, may be remedied by mucilaginous 
and demulcent matters. A dry state of the skin may be relieved by 
direct applications of oil, honey, or glycerine. 

176. Perversion oe secretion often accompanies excess and de- 
ficiency of the process. In febrile diseases, the secretions of the kid- 
neys and alimentary canal are altered as well as diminished. Inflam- 
mation and determination of blood, change, as well as increase the 
secretion from mucous membranes, rendering it more saline, and some- 
times albuminous. The urine exhibits remarkable illustrations of mo- 
dified quality under various circumstances: full living, stimulating 
beverages, and irritations of the digestive organs or kidneys, render it 
unusually strong and acid; low diet, and other causes of weakness, 
generally make it pale and alkaline. Excessive anxiety, fatigue, and 
mental and bodily exertion often increase the proportional amount of 
urea in urine ; sometimes causing the deposition of the phosphates ; a 
result of the increased decay of the, tissues. Out of these morbid con- 
ditions may arise various further decompositions, leading to the de- 
posit of sediments and calculous concretions of different kinds (§ 51, 53.) 
In febrile diseases there is commonly an augmented quantity of uric 
acid in the urine. This is probably because there is then increased 
decomposition of tissue, but at the same time incapacity to perform the 
ordinary processes of oxidation by which uric acid is converted into 
urea. There is therefore then comparative deficiency of urea, and ex- 
cess of uric acid. Oxalic acid is sometimes present in the urine on ac- 
count of the morbid performance of the ordinary retrograde transforma- 
tion of the tissues ; especially in low febrile or cachectic states in which 
it replaces lithic acid, but its strong affinity for lime makes it always 
appear in combination with that base. Oxalate of lime sometimes ap- 
pears in the urine after an abundant deposit of lithic acid. The dis- 
appearance of the chlorides from the urine in pneumonia is an interest- 
ing fact, well established by the observations of Redtenbacher and Dr. 
L. Beale. It takes place especially during the progress of the in- 
flammation, and seems to be clearly traced to the retention of this 
saline matter in the inflamed part (Med. Qhir. Trans., 1852, p. 325.) 
Concretions sometimes result from an altered state of the bile. The 
alvine secretions are greatly modified by various febrile and the ca- 
chectic diseases, being altered in colour, and becoming unusually of- 
fensive in odour. The perspiration is also sometimes modified ; thus 
it is very acid in rheumatism, and fetid in some fevers, and in delirium 
tremens. 

177. Secretions which serve particular purposes, become unfit for 
their offices when they are altered, and thus cause disorder: a thin 
acrid mucus irritates, instead of protecting the membrane which secretes 
it, as in coryza and mucous diarrhoea ; a viscid dry mucus clogs up and 



140 



DISEASES OF THE CONSTITUENTS OE THE BLOOD. 



obstructs tubes -which it was intended to lubricate; altered gastric juice 
causes indigestion ; sebaceous matter of the skin accumulates in the 
follicles when thickened, and thus causes irritation, inflammation, &c. 

178. The appropriate remedies for perverted secretions (§ 176) are 
usually such agents as likewise increase secretion (172, 173.) Thus 
depraved secretions of the intestinal canal are often satisfactorily al- 
tered by continued purging; a turbid state of the urine is sometimes 
removed by diuretics : too thick a state of the mucus of the air-passages 
is modified by expectorants, &c. But when the change depends on al- 
tered circulation in the part, the remedies must be chosen accordingly. 
In some cases, tonics restore a healthy state of the secretions; and in 
most instances of long-continued perversion, tonics may be advan- 
tageously combined with medicines which increase secretion (§ 174.) 
Such a combination is presented in most of those remedial agents which 
have obtained the appellation of alteratives, and which therefore would 
be especially suited to correct the diseased condition under consideration, 
if they really possess the properties that are ascribed to them. 

An accurate knowledge of the nature of an altered secretion often 
guides to the selection of the appropriate remedy for the disorder. 
Thus diarrhoea with a very sour state of the evacuations may be in 
some degree corrected by the administration of magnesia and other 
antacids, combined with purgatives. But as bile is commonly deficient 
in these cases, mercurials may be usefully added to the treatment. An- 
tiseptics, such as chlorine, nitro-muriatic acid, and creasote, are ser- 
viceable where there is extreme foetor of the dejections; but as in these 
cases there is usually some cause of quickened decay and decomposition 
acting on the system (§ 171,) this should be looked for and removed 
or counteracted. Urine turbid from the presence of the lithates is 
most readily cleared by the alkaline diuretics ; that cloudy with phos- 
phates, by acids such as the nitric and benzoic. The viscid mucus of 
bronchial congestion is often connected with a gouty diathesis, and 
yields to alkalies combined with iodide of potassium, squill, or colchi- 
cum. An inspissated condition of bile, leading to the frequent recur- 
rence of jaundice, is in some cases removed by the use of hydrochlorate 
of ammonia, taraxacum, or guaiacum, and in other cases by cod liver oil. 

Nutrition is effected by means of a species of secretion (§ 158;) but 
inasmuch as its operations cannot be understood without a previous 
knowledge of the blood and its constituents, and inasmuch as they in- 
volve the complex subject of structural disease, their consideration is 
best deferred. 



SECTION VII. 
DISEASES OF THE CONSTITUENTS OF THE BLOOD. 

179. The pathological elements (§ 107) hitherto considered are al- 
terations in the vital properties of the elementary solids. We now 
proceed to examine the morbid changes of the blood. These (as in the 



ELEMENTARY DISEASES OF THE BLOOD. 



141 



case of the solids,) may often be traced to the component elements of 
the blood, and they are properly included in the present division, as 
they must be viewed in the light of ultimate elements of disease. But 
as the blood also operates as a whole, compound in itself, although 
simple in its influence on vital functions and structures, it forms a pro- 
per connecting link between ultimate and 'proximate elements of dis- 
ease. So, also, inasmuch as it is, in some respects, an organized com- 
pound, whose materials are changed, together with its functions, and 
which itself contributes to the production of alteration of structure in 
the solids of the body, the consideration of its changes will be a proper 
introduction to that of modifications in the circulation, which in their 
turn induce changes of structure, and thus lead to structural diseases 
themselves. 

180. We have found that blood is the support of all the vital proper- 
ties ; and in describing their variations, we have been obliged to refer 
frequently to differences in the supply or quality of this fluid, both as 
causes and as consequences of these variations, (§ 113^,127, 131, 159, 
&c.) We have now to examine the properties of the blood itself, and, 
first, those which are most elementary, or referable to its respective 
constituents. 

181. The circulating blood consists of red and colourless corpuscles, 
and of the liquor sanguinis, in the proportion of about 512 parts, by 
volume, of moist corpuscles, to 488 parts of liquor; a variation to the 
extent of 40 parts on either side of the 512, being, however, perfectly 
compatible with the state of health. But the liquor sanguinis is itself 
compound, both as regards its constitution and its function. Hence 
several of its ingredients need to be separately specified. The average 
proportions of the chief constituents of the blood are by weight, ac- 
cording to Lehmann, and the views adopted by Dr. Carpenter — cor- 
puscles (consisting of hsematin, globulin, and cell membrane) 149J 
parts, fibrin 2 parts, albumen 39J- parts, fatty matters 2 parts, salts 
and mineral substances (exclusive of iron) 8J parts, extractive matters 
3 parts, and water 795J parts. Hence the following blood ingredients 
have to be brought separately under consideration, as agents in the 
production of disease. 

1. Red corpuscles, ~) 

2. Colourless corpuscles and fibrin, | in excess, 

3. Albumen, \ in defect, 

4. Fatty and other combustive matters, 1 or in altered state. 

5. Saline and mineral matters, J 

6. Water, 

RED CORPUSCLES. 

182. The red corpuscles seem to constitute that portion of the blood 
which possesses calorific and vivifying power, for Prevost and Dumas 
found that animals bled almost to death could be restored by injecting 
into their veins a mixture of red corpuscles and serum, even when the 
fibrin was absent ; but the serum alone failed to produce a like effect. 
Hence it is inferred that it is the red corpuscles that are mainly of 
service when transfusion is performed in cases of hemorrhage. Andral, 
Gavarret, and Delafond remarked that the vigour and beauty of do- 
mestic animals are in proportion to the quantity of red corpuscles con- 



142 



DISEASES OF THE CONSTITUENTS OF THE BLOOD. 



tained in the blood, rather than to that of any of its other elements, 
and that when the characters of any breed are improved by crossing, 
the proportional amount of red corpuscles is increased. Liebig believes 
that the red corpuscles serve to carry oxygen through the system, and 
to bring it to act on all the various textures. There is no doubt that 
the red corpuscles do contain a large proportion of the gases present 
in the blood. Van Maack and Scherer have proved that their fluid 
contents possess a peculiar absorbent power over oxygen. 

183. The red corpuscles of the blood are formed of delicate hollow 
films of a fixed albuminous substance, containing in the interior cavity 
a liquid composed of two peculiar azotized principles mingled together. 
These principles are known to the chemist as globulin and haematin. 
The globulin is seventeen times more abundant than the haematin, and 
is merely albumen very slightly changed by the influence of the cell 
film as it passes through. The haematin is a more highly animalized 
principle of a red colour, and contains a remarkably large amount (7 
per cent.) of iron. It is now generally considered to be the material 
especially prepared by the blood cells for the nutrition of the muscular 
and nervous tissues of the frame. Globulin and haematin seem to hold 
the same position in blood corpuscles that albumen and fibrin do in the 
blood liquid. The red corpuscles appear to contain the principal part 
of the phosphorus, fat, and potash salts that are employed so largely 
in the construction of the nervous and muscular fabrics. Their pro- 
portion to the other constituents of the blood varies in different cases, 
even in health. According to Andral and Gavarret the variation ex- 
tends, either way, from 110 to 152 parts in the thousand. The pro- 
portion is generally from 1 to 2 per cent, less in healthy females than 
in healthy males. It is greater in early adult age than it is at still 
earlier, or at later, periods of life. More red corpuscles are present 
in foetal than in the maternal blood (according to Denis, in the ratio 
of 222 to 140,) and this preponderance is retained for some weeks after 
birth, until, in fact, the blood becomes more watery. 

184. Excess of the red particles might therefore be expected to 
cause a general excitement of the vital properties of the body (§ 183,) 
and this is found really to be the case. Lecanu observed that the red 
corpuscles exist in larger proportion in persons of sanguine tempera- 
ment, especially in vigorous constitutions, than in others. Andral and 
Gavarret detected a slight increase of them in the early stage of in- 
flammation and fever, in some cases, especially in eruptive disorders, 
such as measles and scarlatina. In sanguineous plethora and in he- 
morrhagic diseases before much blood was lost, they were in excess, in 
some instances rising to 185 parts in 1000 of blood. The obvious 
sign of the abundance of red particles is the florid colour apparent in 
the lips, cheeks, gums, and other vascular parts ; the deep blue colour 
of the superficial veins; and the fine deep crimson which a thin film of 
blood gives when spread on a white plate. The bodily functions, ani- 
mal heat, and muscular irritability are in an exalted state, bordering 
on or passing into febrile excitement. Judging by these indications 
we may often infer the existence of an excess of red corpuscles in 
those accustomed to good living, and such an amount of exercise in 



RED CORPUSCLES — EXCESS. 



143 



the open air as suffices to keep the digestive and assimilative functions 
in an active state. 

185. The red corpuscles are deficient in persons of the lymphatic or 
leucophlegmatic temperament (§ 40;) after great losses of blood (arti- 
ficial or from disease;) in chlorosis, and in other ancemic states, such 
as those connected with advanced stages of cancer, diabetes, scurvy, 
and other cachectic diseases; in scrofulous and tuberculous diseases; in 
the latter periods of fevers, and after severe inflammations ; in granu- 
lar degeneration of the kidney, and other organic diseases, especially 
when attended with dropsy; in diseases of the spleen, and others of 
malarious origin (§ 85;) in cases of slow poisoning with lead; 'and in 
persons inhabiting dark and ill-ventilated abodes. In an extreme 
case of chlorosis, the proportion of the red particles was found by 
Andral reduced to 27 in 1000 of blood. 

The signs of the defect are, paleness of parts naturally coloured with 
blood, pallid or sallow hue of the skin, pink colour of superficial veins, 
and a pinkish or light purplish hue of a film of blood spread on a white 
plate. The symptoms of such a condition will be more fully described 
under the head of anaemia ; they pertain chiefly to a weak state of the 
functions generally, comprising those of circulation, calorification, di- 
gestion, and nutrition. 

186. Alterations in the condition of the red corpuscles are evinced 
by changes in the colour of the blood, and in the form of the individual 
corpuscles as seen by the microscope. The colouring matter is evi- 
dently altered in some diseases, being much darker than usual, as in 
the worst forms of scurvy, in which the blood is said, by Mead, to be 
changed to a dark brown or green colour : in the Walcheren and other 
malignant fevers it has been described as pitchy black. In the worst 
forms of cachexia (or rather cacJicemia,) from malarious influence, ge- 
nerally found in conjunction with disease of the spleen, the blood is 
not only very poor, but also perverted in constitution, exhibiting vari- 
ous shades of purple, brown, and even greenish colours. Some change 
seems to occur in congestive typhoid fevers, in which the blood-vessels 
become stained or dyed of a deep claret colour : for this staining im- 
plies a breaking up and unnatural solution of the red corpuscles. 
Probably the occurrence of petechia and ecchymosed patches in these 
diseases is partly dependent on a similar change. The readiness with 
which the textures become stained in scorbutus, in jaundice and albu- 
minuria, and in secondary syphilis, seems to indicate an altered state 
in the colouring matter of the blood; inflammations and ecchymoses 
in the skin are commonly followed by livid, purple, or copper-coloured 
stains. The yellow tinge of the skin in yellow fever, occurring chiefly 
along the course of the large blood-vessels, the peculiar sallowness 
connected with diseased spleen and in chlorosis, and the dark discolo- 
ration around the eyes in the same diseases, apparently proceed from 
a change in the colouring matter of the blood, which causes it to escape 
from the vessels and tinge the skin, as in a part discoloured by a 
bruise. The black matter of melanosis seems to be the colouring part 
of the blood in an altered state, constituting a peculiar pigmentary 
matter : it is likewise so in the spurious melanosis of the intestines. 



144 



DISEASES 0E THE CONSTITUENTS OF THE BLOOD. 



187. Besides changes effected in the colour of the blood, the red 
corpuscles are subject to alterations in their form, size, and other pro- 
perties effected through the influence of the medium in which they are 
placed. It was first observed by Hewson, that pure water causes them 
to swell, become globular, and burst; whilst saline solutions, containing 
more salts than serum does, make them shrink in size. These changes 
are now generally understood to arise from endosmosis and exosmosis : 
the saline matter drawing the water into or out of the little cell, which 
with its contained colouring matter, constitutes the red corpuscle. It 
is highly probable that similar changes may take place in the living 
body, when circumstances greatly alter the proportion of saline matter 
and water in the blood. Such changes may possibly contribute to 
produce the serious symptoms, and even the sudden death, which have 
ensued on drinking a large quantity of water after great exertion. 
Has it also aught to do with the reaction and irregular excitement that 
sometimes occur after excessive losses of blood? Or with the symp- 
toms of suffering which animals manifest on the instant when water is 
injected into their veins? Dr. Owen Bees has suggested that the re- 
markable diminution of the blood discs in cases of albuminuria may be 
due to their destruction in consequence of the draining away of albu- 
men from the blood, and its subsequent reduction to a very watery 
state ; the same circumstance may also prevent their redevelopment 
from the chyle and lymph both in these cases and in chlorosis. In 
several cases of Bright's disease of the kidney I have observed the 
blood discs to be jagged or crenate at their margins, and otherwise 
imperfect; and the same remark has been made by Simon of Berlin 
and others, and by Andral in a case of chlorosis. In one fearfully 
rapid example of albuminuria, which proved fatal in six days, with 
effusion of pus in the joints the day before death, I found the colouring 
matter dissolved in the bldod-iiquor after death, and scarcely any red 
discs remaining. There were also numerous pus globules in the blood. 
A similar total destruction of the blood discs was observed in Univer- 
sity College Hospital in the blood of a person who died of malignant 
scarlet fever with purpura. I have met with similar proofs of break- 
ing up of the red particles, but to a much smaller extent, in acute 
purpura connected with jaundice, and in cases of disturbed function 
of the liver without jaundice. Is this due to the remarkable solvent 
power which small proportions of bile exert over the red particles, as 
noticed by Simon and others? 

188. The change of the blood from dark to florid, on the addition 
of saline matter, appears to depend on the increased density and white 
opacity then given to the corpuscles, whereby they are rendered less 
transparent and more abundantly reflective of light. 1 Probably the 
action of oxygen in reddening venous blood is of a similar character, 
for it also renders the blood' less transparent. This explanation of the 
colour of arterial blood was suggested to me by some experiments 
which I made in 1835, and in some measure corresponds with the opinion 
of Dr. AYells, 2 that the brighter colour is due to fine mechanical division. 



i Medical Gazette, Sept., 1835. 



2 Phil. Trans., 1795. 



RED CORPUSCLES — ALTERATIONS. 



145 



Dr. J. Davy, in 1888, expressed a like conclusion. Mulder's notion, 
more recently advanced, that the florid colour of the arterial blood is 
caused by the formation of a film of deutoxide of protein on each cor- 
puscle, is in accordance with this explanation as regards the influence 
of oxygen, but it hardly meets the case of the more rapid and complete 
brightening of blood by saline matter. Dr. Carpenter suggests that 
the brightening of blood may be due to the corpuscles becoming more 
empty and therefore assuming the biconcave form, whilst the darken- 
ing depends on their swelling to a more globular shape. Still it is the 
change in density rather than change in shape that would alter the 
reflective power. I have noticed that the dark fluid blood found in 
the body during malignant scarlatina, and other bad congestive fevers, 
does not redden so soon as usual on exposure to the air. The same 
remark applies in some of the other cases of alteration of the red cor- 
puscles mentioned above (§ 187.) 

189. The red corpuscles are distinct structures, living cells, isolated 
and floating in a lifeless fluid. Like other living cells, they appear to 
possess the power of secretion. They certainly form the red colouring 
principle and the globulin which they contain. It has been conjectured 
that they have yet other vital properties, such as spontaneous motion, 
and the power of attraction and repulsion; but there are no unequi- 
vocal facts that can support such notions. The motions described by 
Treviranus, Schultz, and others, may be accounted for on purely phy- 
sical principles. It is said, that a systolic and diastolic movement in 
blood particles has been observed by Dr. Martin Barry in the Fallopian 
tube of a recently impregnated rabbit ; but this seems to have been 
effected by the cilia of the membrane. 

190. Hewson, Prevost, Dumas, and others, observed that the red 
corpuscles of new-drawn blood cohere together in piles or rouleaus. 
This cohesion in healthy blood is of very short duration : for it may be 
seen, as first remarked by Dr. Hermann Nasse and Mr. Wharton Jones, 
that in a few seconds the adherent discs float about loosely among each 
other again ; but in blood drawn from a person affected with inflamma- 
tion, this cohesion takes place more readily, is more firm, and lasts for 
a longer time ; it has been considered that this is the chief cause of 
the separation of the red particles from the fibrin, which then consti- 
tutes the buffy coat. "We shall notice the relation of this phenomenon 
to the formation of the buffy coat under the head of fibrin; but for the 
present we would remark of it that it is not certain that the cohesion 
of the red corpuscles is more than a case of mechanical aggregation 
modified by changes in the relative dilution of the liquor sanguinis, 
and the contents of the blood corpuscles. The momentary exposure of 
a thin film of blood to the air causes evaporation from the serum without 
affecting the contents of the blood corpuscles as instantaneously; these 
then cohere; but the exosmosis of fluid from their interiors soon again 
detaches them from each other. 1 Without however dwelling on this, 

1 Hence, as it has been remarked by Mr. Gulliver, the addition of a little salt prevents 
the cohesion of blood discs. I do not assert that there is nothing vital in these properties 
exhibited by the organized parts of the circulating fluid, but I must protest against the 
hasty assumption made by some physiologists, that the motions and alterations revealed 

10 



146 DISEASES OF THE CONSTITUENTS OF THE BLOOD. 

or the equally hypothetical notion that the cohesion is due to a vital 
attraction, we may remark that it is important to bear in mind what 
has been stated to occur where inflammatory disease is present. In- 
deed it has been supposed that a similar aggregation of the blood cor- 
puscles then takes place within the capillaries, and is the cause of the 
obstruction there. But although the blood corpuscles are sometimes 
seen to aggregate in masses within the larger vessels of a frog's web, 
when the motion of the blood is arrested by pressure on a vein, this 
aggregation is speedily broken up when the obstruction is removed; 
and the more permanent accumulations in the vessels of an inflamed part 
will be hereafter shown to be, sometimes at least, due to obstruction set 
up by the colourless particles, and their adhesion to the sides of the ves- 
sels. (See Inflammation.) 

191. There is still much doubt concerning the manner in which the 
red corpuscles originate. During early embryo life they unquestion- 
ably multiply by a process of subdivision. Each then contains a nu- 
cleus cell, which parts into two, a new corpuscular vesicle being then 
developed round either half. In more mature life this process of mul- 
tiplication by division does not seem to be continued. There is no 
nucleus whatever in the completed adult red corpuscle of the human 
blood. The reel corpuscles appear to be then formed out of the chyle 
and lymph globules, through some unknown course of transmutation. 
Mr. Paget believes that he has seen colourless corpuscles change into 
coloured ones ; but there is a higher probability in the notion that the 
coloured and the pale corpuscles are independent formations, designed 
for distinct offices, but both originating in a common source, the chyle 
and lymph globule. The development, growth, and decay of the red 
corpuscles go on simultaneously and indiscriminately in all parts of 
the circulation, but are in a great degree dependent on the active state 
of the organs of nutrition, as well as on that of the great depurative 
organs (the lungs, liver, and other glands,) and on a due supply of the 
ferruginous element that enters so largely into their composition. — 
(Br. Mann.) 

The influences which promote the decay and retard the formation 
of the red particles (§ 185, 186,) are chiefly circumstances which impair 
the nutrition of the body ; but there are some of these which affect the 
red particles much more than they do other components of the frame. 
Two of the most remarkable are a diseased state of the spleen, and 
disordered uterine function. The striking pallidity, or pale sallow 

in animal and vegetable fluids by the microscope are all dependent on a mysterious vi- 
tality. If any microscopical observer will take the trouble to watch the behaviour of a 
light flaky precipitate recently thrown down from a solution in water and spirit, he will 
see motions and aggregations as remarkable as those of the recently effused blood discs, 
although less regular from the unequal size and shape of the particles. The close and 
orderly arrangement of the blood discs is favoured by their mobility and flatness, which 
facilitate the operation of the aggregative force ; and in this respect they contrast with 
the white globules, whose globular shape and larger mass render them less apt to coalesce ; 
these however often form centres, around which rolls of discs cluster in circles or rays. 
It is remarked by Mr. Gulliver, that the elliptical blood corpuscles of reptiles and camels 
cohere together in irregular heaps, devoid of the rouleau arrangement seen where round 
discs are concerned; it is therefore highly probable that the cohesion is due to some me- 
chanical influence. 



Pi ED CORPUSCLES — FORMATION AND DECAY. 



147 



hue, of persons "who have been long suffering from malarious influence, 
particularly in warm climates, has often attracted attention ; it is now 
generally considered that these are cases in which the spleen has be- 
come diseased, an acknowledged result of the continued operation of 
malaria. The general state of the blood in these affections has been 
already noticed (§ 186 ;) and it may now be farther explained that a 
' diseased spleen operates not only by withdrawing from the circulation 
an undue proportion of blood, but also by keeping it in a stagnant state, 
unrenewed and unpurified through circulation and excretion ; it spoils 
the blood itself, and renders it unfit for farther use. Hence, when in 
lapse of time portions of this spoilt blood are again returned into ac- 
tive circulation, they corrupt and contaminate the whole mass, and 
induce the various kinds of cachosmia or cachexia which form the 
sequels of malarious diseases. This view accounts for the fact, often 
considered unintelligible, that such morbid effects result only from en- 
largements of the spleen, and not from its entire obliteration, which 
last has been repeatedly noticed to occur without the production of any 
peculiar effect on the blood. Other instances of a similar character 
will be mentioned under the head of congestion. 

The mode in which amenorrhea tends to impair the quality and 
quantity of the blood corpuscles may also derive some light from the 
foregoing remarks. A young female, during or before menstruation, 
is exposed to continued cold, or to sudden mental excitement ; the dis- 
charge is checked; and if no serious illness immediately ensues, she 
begins to fail in strength, and in a few weeks or months becomes chlo- 
rotic. The uterine system remains congested after the repression of 
the discharge ; and the blood in the system suffers, not only from the 
interruption of the process of excretion (M. Gay Lussac and Andral 
have proved menstruation to be such, for during the flow the quantity 
of carbonic acid exhaled by the lungs is much diminished) (§ 170,) but 
also from the influence of a reservoir of the impure blood which tends 
gradually to derange and contaminate the whole mass. 

192. Remedial measures. — Excess of the red corpuscles may be 
speedily removed by blood-letting, for they are diminished in quantity 
by the employment of such means much more rapidly than the other 
constituents of the blood. Low or vegetable diet, and the antiphlogis- 
tic regimen generally, including the avoidance of all stimulating or 
exciting agents, produce a similar effect, although more tardily. It is 
not certain whether any medicines produce the same result by direct 
influence ; but cholagogue purgatives, and the continued use of mer- 
cury, colchicum, and other medicines which largely increase the excre- 
tions (§ 173,) ultimately reduce the proportional amount of the red 
corpuscles. The dark green evacuations produced from the bowels by 
the continued action of calomel, and other preparations of mercury, 
appear, from the observations of Dr. Golding Bird, to consist of altered 
hsematin. This operation of calomel may therefore be well considered 
as closely allied to blood-letting. Mineral saline waters, and saline 
medicines taken copiously and in a state of much dilution, sometimes 
diminish extreme rubicundity of the surface in so remarkable a degree 
as to suggest the notion that when absorbed into the mass of the blood 



148 



DISEASES OF THE CONSTITUENTS OF THE BLOOD. 



they may directly destroy some of the red corpuscles; they are there- 
fore useful cooling agents where these are in excess. The remarkable 
pallidity which accompanies the occurrence of extensive suppuration 
would also point to the formation of pus as a means for diminishing 
the red corpuscles ; and this formation may be artificially effected by 
the employment of setons and suppurative counter-irritants. 

193. As regards the increase of the red corpuscles, when in deficient 
quantity ', it might be expected that nourishing food, and especially the 
free use of brown meats, exposure to invigorating air and light, and the 
employment of tonics generally, would be the proper means to promote 
it. But without the teaching of experience we could never have antici- 
pated that medicines containing iron should possess such remarkable effi- 
cacy as we find to be the case in relation to this element of disease. In 
many cases of chlorosis, under the use of any suitable preparation of 
iron, the complexion will change from waxy to ruddy, in three or four 
weeks' time. In the choice of the preparation of iron best suited to 
accomplish this purpose we must be guided by the state of the stomach 
and other considerations, but the most soluble preparations are th« 
most effectual when they can be borne; and this is of more importance 
than the particular combinations in which they are administered : thus 
the iodide, sesqui-chloride, sulphate, citrate, acetate, and acid phos- 
phate, are all severally eligible. This subject will again come under 
consideration in connexion with anemia. 

It has been supposed by Dr. Stevens that saline medicines have great 
power in restoring to their healthy state the red corpuscles which are 
changed in typhoid and malignant fevers (§ 186 ;) but if these remedies 
are beneficial in such maladies, it is very doubtful whether much is to 
be ascribed to this mode of action. It is more probable that the good 
results from the removal of the diseased corpuscles out of the system 
through increased excretion (§ 192,) at the same time that fresh cor- 
puscles are produced by the influences suggested above. Thus in ma- 
larious and ansemic cachaemia, the best effects result from the combined 
use of purgatives, diuretics, and chalybeate tonics. Hence the advan- 
tage accruing from the operation of saline chalybeate waters, which 
promote the elimination of decayed blood, at the same time that they 
promote the formation of more of a better quality. 

The disposition of the red corpuscles to coalesce, which is augmented 
as we have seen in inflammation, is diminished by the addition of saline 
matter to the blood; and Mr. Gulliver has surmised that a part of the 
useful operation of saline medicines in inflammation may be due to this 
cause. 



SECTION VIII. 
FIBRIN AND WHITE CORPUSCLES. 

194. Fibrin and albumen cannot be distinguished from each other 
by difference of chemical composition. Liebig maintains that they are 
chemically identical; but Dumas considers that fibrin has rather more 



FIBRIN — NATURE AND OFFICES. 



149 



nitrogen in it than albumen. Fibrin is, however, characterized by one 
peculiar property, of the utmost importance in its physiological and pa- 
thological bearing — its readiness to become organized. For a long time 
it has been considered to be the organizable material of all the tissues 
in its final stage of preparation, and just about to become organized. 
Now, however, it is known that it is only the fibro-gelatinous textures of 
low vitality that it forms. Its own high organizable power peculiarly 
fits it to become the material of structures that have little formative 
strength in themselves. But besides furnishing the substances out of 
which the fibro-gelatinous tissues are made, fibrin serves the highly 
important office of conferring certain physical properties upon the 
blood, that are necessary to it as circulating fluid. A slightly viscid 
fluid moves more readily in narrow tubes than water itself, but at the 
same time it is less prone to escape through the minute pores in the 
walls of the containing tubes. The fibrin present in the blood guards 
against the occurrence of too ready transudation and hemorrhage, and 
leads to their limitation within safe bounds when accidental openings 
of escape are made. 

Being the constituent then which confers coagulability on the blood, 
in all the varieties which that process exhibits, and which furnishes 
coagulable lymph, it becomes a very important agent in the mainte- 
nance of health or the production of disease. Although probably not 
so immediately concerned as the red corpuscles in sustaining the vital 
processes of respiration, circulation, and innervation, its presence is 
nevertheless essential to the active state of these processes, as well as 
to that of the nutritive and reparative function ; and it therefore exists 
in larger proportion and higher perfection in arterial than in venous 
blood. Although, as above stated, it is distinguished from albumen less 
by chemical differences than by its ready organizability and suscepti- 
bility of life, yet there are certain conditions, chemical as well as phy- 
sical, which are favourable to its formation, and by knowing these we 
are able to influence its production at will. 

Fibrin, as presented to us in washed clot, coagulable lymph, or the 
buffy coat of inflamed blood, consists of a mass of extremely fine fibres, 
containing scattered among them transparent granular bodies, some 
separate, and others in round encysted clusters. In fluid blood we 
see the same granular bodies or pale corpuscles, but none of the fibres. 
The capability of forming these fibres seems to be the great characteristic 
of fibrin, and its power to assume this fibrous state distinguishes it from 
albumen, which solidifies in a granular mass. So long as fibrin re- 
mains dissolved, as in the blood liquid, it is in no way distinguished 
from the albumen with which it is combined, but it even then has the 
inherent capacity to solidify in a peculiar manner. This capacity, 
from the time of J. Hunter to the present, has been generally consi- 
dered to be an attribute of indwelling life; undoubtedly it is connect- 
ed with vital activity in the sanguiferous functions ; but various facts, 
particularly some pointed out by Dr. Buchanan of Glasgow, and Mr. 
Gulliver, show that the fibrillation of fibrin, like the crystallization of 
a salt, is promoted by, and sometimes even dependent on, the presence 
of fibrin already solidified, of the pale corpuscles, or of some other 



150 



DISEASES OF THE CONSTITUENTS OE THE BLOOD. 



kindred matter. Exposure to the air, and dilution with water, also 
favour the consolidation of fibrin. The former is probably essential 
to the result; for the circumstances which promote the formation of 
fibrin in the blood, generally include a certain degree of increased 
oxygenation. In fact, according to Mulder, fibrin is chemically an 
oxyprotein, or more definitely, the deutoxide of protein, and that its 
formation is in part at least dependent on the process of 0x3^ elation, 
is probable from the fact that arterial blood contains more fibrin 
than venous, and of a more perfectly fibrillating and contractile 
quality. 

But while fibrin is thus viewed with regard to its mere mechanical 
and physical nature, we must not lose sight of the peculiar relation in 
which it stands to vital properties, which attach 'themselves to it more 
than to any other constituent of the blood. Its fibres and granules 
are the rudiments of new living textures ; and while observing its me- 
chanical construction and its chemical constitution, we are only noting 
the conditions which render a highly annualized material fit for the 
peculiar offices of life. ^ 

The average proportion of fibrin in the blood of a healthy adult is 
between two and three parts in every thousand. Within the limits of 
health it may vary from two to three and a half parts, being most 
abundant in well-fed persons with active circulation during advancing 
growth ; and least in early infancy, and in persons of weakly consti- 
tution and advanced age. It has been frequently observed that a 
greater number of colourless corpuscles are present whenever the 
fibrin of the blood is in marked excess. This has led some physiolo- 
gists to adopt the view that fibrin is formed through the agency of 
these bodies; that indeed the main office of the colourless corpuscles 
is to transmute crude albumen into plastic fibrin. By others it is 
deemed more probable that the colourless corpuscles do for the other 
albuminous textures what the red corpuscles do for muscle and nerve, 
that is, prepare the material especially suited for their nutrition. 
Practically it is quite impossible to separate the fibrin and the colour- 
less globules, and hence all estimates of the quantity of fibrin include 
the colourless corpuscles present, whatever the amount may be. Dr. 
Carpenter remarks that in a general way the colourless corpuscles may 
be deemed to be superabundant in comparison with the fibrin, when a 
bulky clot is of loose consistence and easily broken between the 
fingers, and the converse when it is very tenacious and firm. I have 
found the corpuscles always abundant in the fibrin and coagulable 
lymph of scrofulous subjects. 

195. An excess of fibrin, and of colourless corpuscles (hyperplasma, 
or hyperinosis,) exists in all true inflammatory diseases, especially 
those of a sthenic character, and in young subjects, and in acute 
rheumatism. In some cases of pneumonia and rheumatism, MM. An- 
dral and Gavarret found the proportion as high as 13.3 parts in a 
thousand. It is stated by them that inflammation never occurs unless 
the fibrinous constituent of the blood amounts to five parts in a thou- 
sand. So likewise whenever an inflammation supervenes in the course 
of another disease, there is always an augmentation in the quantity 



EXCESS OE EIBRIN AND WHITE CORPUSCLES. 



151 



of fibrin in the blood. The proportion of fibrin is also increased du- 
ring the latter months of pregnancy. 1 MM. Andral and Gavarret 
observed an increase of fibrin in tuberculous diseases, in which we 
have noticed that there is a deficiency of red particles (§ 185.) In 
one case of phthisis, Popp found the proportion of fibrin to amount 
to 10.7 parts in a thousand. This result is now generally attributed 
to the inflammatory action that is induced around tubercular deposits. 
Mr. Gulliver has observed the increased quantity of white globules in 
blood drawn in inflammation, and I have noticed this as occurring 
within the vessels. (See Inflammation.) It has been supposed that 
the increase of fibrin in inflammation may be due to the accelerated 
movements of circulation and respiration, which might augment the 
changes of the blood in the lungs ; and in some experiments by Dr. 
Gairdner, an increase of fibrin was produced in the blood of rabbits 
by making them breathe pure oxygen, or by exciting the respiration 
by galvanism. But it must be remarked that the amount of fibrin in 
inflamed blood is by no means in proportion to the frequency either of 
the pulse or of the respiration. There are other diseases, chlorosis 
for instance, in which blood drawn exhibits a fibrinous or buffy coat, 
without there being any absolute increase of the fibrin : this will be 
noticed presently. This is observed in various states of atrophy and 
cachexia, whether connected with deficiency of blood, defective powers 
of digestion and assimilation, or excessive expenditure of the nutrient 
fluid. An excess of fibrin, and still more so of the white corpuscles, 
has been noticed to exist in certain cases of anosmia, generally in con- 
nexion with enlargement of the spleen, liver, and lymphatic glands. 
The predominance of the pale corpuscles has led Professor J. Hughes 
Bennett 2 to coin the word leucocythsemia to designate this affection: 
its true pathology remains in obscurity; but it is probably a disease 
of the cell-formation of the blood, in which, instead of normal red 
corpuscles, cells are produced without colouring matter, and advance 
no further. Three cases of this kind, which have recently fallen 
under my observation, derived no advantage from the use of ferrugi- 
nous medicines. 

196. Deficiency of fibrin (hypinosis) is of frequent occurrence in 
many diseases, and temporary conditions bordering on disease. Its 
sign is fluidity, or imperfect coagulation of the blood after it is drawn. 
As venous blood contains less fibrin and of a less perfect quality than 
arterial, so the quantity is absolutely diminished when the blood is 
more venous than usual, as in cases of asphyxia or impeded breathing ; 
and in those of cyanosis, in which the venous blood becomes mixed 
with the arterial in consequence of the existence of an unnatural 
opening. Excessive bodily fatigue more or less expends the fibrin ; 
hence the blood often remains fluid in animals hunted to death (§ 65.) 
It was stated by John Hunter that the same thing may be observed 
in animals killed by lightning ; but Mr. Gulliver has shown that this 
is not generally the case. In many instances the blood is found fluid 

1 In domestic animals the proportional amount of fibrin is diminished before, and in- 
creased after, parturition. (Ann. de Chim. 1842.) 

2 Edinburgh Monthly Journal. 1851. 



152 



DISEASES OF THE CONSTITUENTS OF THE BLOOD. 



in cases of death from poisoning and other suddenly acting influences. 
In some of these the deficiency of fibrin may be attributed to im- 
peded respiration, which is the immediate cause of death. This is the 
case when poisonous doses of hydrocyanic acid, opium, and strychnia 
are taken, when apoplexy occurs, and when the pneumogastric nerves 
are divided (Dupuy.) There is, however, some uncertainty about 
these facts. (See Mr. Blake's experiments mentioned further on.) 
In other instances, — as in poisoning with arsenic, sulphuretted hydro- 
gen, and some other pernicious agents, — the fluid state of the blood 
must be ascribed to a more direct operation on the blood itself. So 
likewise in adynamic fevers, which arise from the presence of a pe- 
culiar poison in the blood, its fluidity or imperfect coagulability is 
one of the most remarkable conditions, and seems to be a chief cause 
of the hemorrhages, petechia, and vibices, which sometimes then 
occur. In a case of very low typhoid fever, Andral found that there 
was less than one part of fibrin in each thousand of blood, and he 
states that the proportion never rises above 3.7 parts in the 1000 in 
ordinary continued fevers. In one instance of abdominal typhus, 
Simon could find no trace whatever of fibrin in the blood. The arti- 
ficial imitation of this kind of fever, produced in dogs inoculated 
with various morbid or putrid matters, or confined over their exhala- 
tions, in the experiments of Gasparcl, Magendie, Gendrin, Leuret, 
and Ham on, exhibited the result of a similar deficiency of fibrin in 
the blood (§ 194.) In one case of putrid fever, Scherer observed that 
the deficiency was accompanied by the presence of carbonate of am- 
monia in the blood, doubtless the result of incipient decomposition. 
In the eruptive fevers the proportional amount of fibrin is not so much 
diminished, but neither, on the other hand, is it so much increased as 
in other inflammatory disorders. The febrile and the inflammatory 
condition seem to modify and antagonize each other's influence to a 
certain extent as regards the composition of the circulating fluid. In 
epidemic cholera the fibrin is invariably deficient in the blood. M. 
Andral also found a diminution of fibrin in cases of cerebral conges- 
tion, with headache, vertigo, and tendency to epistaxis. In apoplexy 
the diminution was even more remarkable, and in one case was as low 
as 1.9 in 1000 during the state of unconsciousness ; but on the third 
day, when the apoplectic symptoms were subsiding, it? rose to 3.5. 
This rapid change seems to suggest that the oppressed state of the 
functions, especially of the breathing, may have reduced the propor- 
tion of fibrin. 

When some neutral and alkaline salts are added to the blood out of 
the body, its coagulating property is lessened, and it has been stated 
that subsisting on salted food will produce a thin or hypoplastic state 
of the blood during life ; but this statement does not appear to be 
founded on any well ascertained facts, and is perhaps connected with 
the notions, that salt food is the cause of sea scurvy (§ 63,) and that 
the blood does not coagulate in this disease, both of which are erroneous. 
(See Lib. of Prac. Med., Art. Scurvy, by Dr. G. Budd.) 

197, Besides the state already mentioned, — permanent fluidity or 
little coagulation of the blood when drawn, — a defect of fibrin in the blood 



DEFICIENCY OF FIBRIN. 



153 



causes a tendency to various kinds of hemorrhage, generally of the 
asthenic kind, and to an unmanageable oozing of blood from any ac- 
cidental wound or breach of texture. In a case of purpura hemor- 
rhagica, Routier found the fibrin reduced to less than one per thousand. 
Under the same circumstances, too, wounds do not readily heal, nor 
fractures unite. In fact, the plastic or reparative process is at fault 
for want of its material (§ 194;) and for a similar reason, the nutrition 
of textures which are allied to fibrin, such as the fibro-gelatinous tissues, 
is then imperfectly maintained. 

198. Magendie found that when the fibrin was abstracted from the 
blood of animals, they were affected with congestions and effusions in 
the lungs, brain, and other organs. This he ascribed to a cause sup- 
posed by M. Poisseuille to be the expression of a general physical fact ; 
namely, that very thin fluids pass through capillary tubes less readily 
than fluids of somewhat greater consistence. His experiments were, 
however, too rude, and his deductions too hasty, to merit confidence ; 
the obstructions and congestions alluded to might have been due to the 
cohesion of colourless or red corpuscles, or even to the deposits of little 
clots of fibrin left by the processes employed. There can, however, be 
no doubt that a certain spissitude in the blood is favourable to its 
transit through the hydraulic apparatus of the circulation; and that 
when this is deficient, various irregularities in the distribution of the 
fluid may occur. Some of these will be mentioned under the head of 
anaemia : but I may mention here that preternaturally thin blood is 
easily thrown into sonorous vibration, and that various unusual sounds 
or murmurs in the heart, arteries, and veins, may be thus produced. 
As these sounds are sometimes met with in cases in which the com- 
plexion does not indicate a deficiency of red corpuscles in the blood, 
and as they are sometimes absent in the most pallid subjects, I am in- 
clined to connect them as much with deficiency of fibrin and albumen 
as with that of the red corpuscles of the circulating fluid. 1 

199. The consideration of alterations in the quality of the fibrin 
brings under our notice certain important morbid appearances that the 
buffy coat and the blood-clot occasionally present. 

As the consolidation of the fibrin is the cause of the coagulation of 
the blood, so differences in the proportions and properties of the fibrin 
affect the state and appearance of the coagulum. 

200. A large firm coagulum indicates an abundance of fibrin, as 
well as of red particles, and is commonly presented by healthy blood. 
A loose coagulum implies a deficiency of fibrin. A small firm clot be- 
tokens an abundant proportion of fibrin with some deficiency of red 
particles ; but the smallness of the clot points to excess in another pro- 
perty of the fibrin, that of contraction during and after its consolida- 
tion. The upper part of the clot is commonly more contracted than 
the lower portion ; it is also firmer and contains more fibrin, whilst the 
lower abounds more in red particles. Here there is evidently a ten- 
dency to a separation of the red particles from the fibrin. In some 

1 This inference has been confirmed by the subsequent observations of MM. Becquerel 
and Rodier, who found that in the pallid cachexia produced by the poisonous influence 
of lead, the albumen is not diminished, and the vascular murmurs are not present. 



154 



DISEASES OF THE CONSTITUENTS OF THE BLOOD. 



cases, the separation is, to a certain extent, complete, the red particles 
subsiding, whilst the fibrin rises to the surface, and forms at the top 
of the clot a layer of a light yellow or buff colour, commonly known by 
the name of the huffy coat. 

It may be inferred, then, that besides coagulation (§ 194,) fibrin 
possesses a property of contraction, and another of separation from the 
red particles. These properties are severally presented in different 
degrees of activity in different states of the system. Let us then 
consider their influence, first separately, and afterwards in mutual re- 
lation. 

201. Coagulation is generally retarded in inflammatory diseases, and 
in other cases in which the fibrin is abundant (§ 195;) the amount of 
fibrin present is indicated by the firmness and size of the clot. The 
coagulation is tardy also in the opposite condition ; where the fibrin is 
scanty ; but then the clot is very loose, and where the fibrin is very 
deficient, there may be no coagulation at all. Other circumstances 
may make the coagulation slow, as warmth and seclusion from the air ; 
whereas rapid cooling, and exposure to the air (as when the blood 
trickles from the vein, or is drawn into a shallow vessel,) hasten the 
coagulation. A temperature of 150° totally destroys the coagulability 
of the blood. The addition of some saline matters, such as common 
salt, nitre, or carbonate or sulphate of soda, retards the coagulation of 
the blood. Mr. Gulliver found that the blood of a horse to which nitre 
had been added, remained fluid for fifty-seven weeks, yet even then 
coagulated, on the addition of water. 

Contact with dead organic matter promotes coagulation, and most 
especially when that matter is at the time undergoing degradation. 
Mr. H. Lee 1 found that when putrescent pus was injected into the ju- 
gular vein of an ass, the vein instantaneously became like a rigid cord, 
in consequence of the deposit of fibrin within it. It is probable that 
pus is often shut up in the channels of the circulation, and rendered 
harmless, by an investment of fibrin being thrown around it. MM. Du- 
puy and De Blainville found that the injection of cerebral substance into 
the veins of a living animal caused instant death by the sudden forma- 
tion of clots in the heart and large vessels. 

The coagulum of the blood is dense in proportion to the elaboration 
the fibrin has undergone. But the specific gravity of the blood is not 
by" any means a test of its coagulability; the heaviest blood is often 
that which has most corpuscles and least fibrin : the length of time that 
ensues before coagulation takes place, and the degree of solidification 
that ensues, are often in inverse proportion to each other. The last 
part of a stream of blood generally coagulates the most rapidly and 
the least firmly. 

Contact with the lining coats of a living vein seems to retard coagu- 
lation, unless the vessel be in a state of inflammation. Dr. Carpenter 
represents the liquid condition of fibrin, while in the circulating blood, 
as being the consequence of a sort of balance of forces, the living tis- 
sues with which it is in contact tending to keep it fluid and its own 
plastic nature to render it solid. 2 It seems evident that all causes 

1 On the Origin of Inflammation of the Veins and on Purulent Deposits. 

2 Principles of Human Physiology, 1858, p. 184. 



FIBRIN — SEPARATION — BUFFY COAT — CAUSES. 



155 



which impair the elaboration of fibrin also diminish the plastic property 
of the blood. 

202. The contraction of the clot evidently depends on the attraction 
of the particles of fibrin for one another after the coagulation has 
begun. By the contraction, the red particles entangled in the fibrin 
are also pressed together, whilst a portion of the serum is squeezed out. 
The more slow the coagulation is, generally the greater will be the 
contraction. Hence as the upper surface of the clot is often formed 
more quickly than the lower, it is also larger ; but the central portions 
of the large upper layer are drawn downwards by the stronger con- 
traction of the mass below, and in this way is caused the concave or 
cupped appearance in the clot, so commonly seen in buffed blood (§ 200.) 
When blood is drawn from a vein slowly, or received into a shallow 
vessel, the coagulum is speedily formed in all parts, adheres to the 
sides of the vessel, and is not cupped. As the contraction and cup- 
ping of • the clot are due to the fibrin, it might be expected, h priori, 
that these results would be marked or otherwise in proportion to the 
amount of fibrin present. This is the case in inflammatory diseases. 
But there is also great contraction, and often cupping, in chlorosis 
and some analogous states, where the fibrin is not absolutely increased ; 
here the red corpuscles are so deficient, that they do not offer the usual 
resistance to the contractile influence of the fibrin. For a similar 
reason the contraction is greatest where the fibrin is most completely 
separated from the red particles. On the other hand, there is little 
or no contraction where the red particles are in great abundance, as 
in sanguineous plethora (§ 184,) or where the aggregation of the fibrin 
is impaired by the addition of saline matter (§ 196.) In a boy suffer- 
ing from purpura, under my care, Dr. Garrod found the fibrin in the 
blood to be quite as abundant as usual, amounting to 3 in 1000 parts, 
but it was remarkably defective in the usual contractile property, and 
the salts of the fluid were in excess. 

203. The separation of the fibrin from the red particles (§ 200,) ex- 
hibited in the formation of the buffy coat, has attracted much attention, 
and has been ascribed to various causes. As the fibrin always rises 
to the surface, and the red corpuscles as constantly sink, it is obvious 
that one chief reason for the separation is the greater weight of the 
latter. They subside entirely from the upper layer of fibrin before it 
has time to coagulate. Consequently this result may be favoured by 
four different circumstances: — 1, tardy coagulation of the fibrin giving 
more time for the subsidence ; 2, increased specific gravity of the red 
corpuscles ; 3, diminished specific gravity of the fibrin ; 4, diminished 
thickness of the liquor sanguinis. Now two of these conditions may 
be produced by adding a little salt to healthy blood as it flows from 
the vein ; and this addition really does produce a separation of the 
fibrin ; but the fibrin then rising to the surface has neither the con- 
tractile power (§ 203) nor the firmness of the inflammatory buff; it is 
gelatinous like size, and resembles the sizy film sometimes exhibited 
in scurvy and diabetes. Farther: although blood in inflammation is 
generally slow to coagulate, it is not so always ; and in extreme cases, 
as in acute rheumatism, the buff appears even where the coagulation is 



156 



DISEASES OE THE CONSTITUENTS OF THE BLOOD. 



speedy, and, according to Schroeder Van der Kolk, is seen in patches 
and thin films in places where gravitation could not have been opera- 
tive in promoting the separation. 1 There must therefore be some 
other cause for the formation of the buffy coat, besides the one above 
named. The great firmness and contraction of the surface in the clot 
of inflamed blood may be ascribed to the increased proportion of fibrin, 
which is then constantly present. 

204. Dr. Alison considers the separation of the fibrin in inflamma- 
tion to be due to a vital repulsion acting between the fibrin and the 
colouring matter. Dr. Hermann Nasse and Mr. Wharton Jones think 
that it may be entirely accounted for by the increased aggregation 
(before noticed, § 190,) then observed in the red corpuscles (Brit, and 
For. Med. Rev., Oct. 1842, p. 592.) The cohesion of the red corpus- 
cles into connected piles or rouleaux may facilitate the separation, not 
only by the direct influence of the separative aggregation, but also 
because the connected mass sinks through the liquid fibrin more, quickly 
than separate particles would; just as bits of chalk fall to the bottom 
of water instead of remaining long suspended, as they would do if in 
the state of fine powder. Mr. Gulliver has observed that the red cor- 
puscles sink rapidly in proportion to the amount of this aggregation. 
Another circumstance most probably favouring the separation of the 
buffy coat, is an increase in its own lightness, due to an augmented 
proportion of fat globules mixed up with the pale corpuscles diffused 
through it. 

205. In order that the true characters of the clot may be exhibited, 
the blood should be drawn by a full stream into a deep or globe-shaped 
basin or cup, previously warmed, and should be kept covered over 
until the coagulation is complete. These precautions serve to retard 
the coagulation, and to favour the separation and contraction of the 
fibrin. On the other hand, if the blood merely trickles from the vein, 
as when the orifice is small or the patient faint, or if the receiving 
vessel is shallow and cold, the blood congeals at once, and the appear- 
ance of the buffy coat is prevented (§ 202.) This is one reason why 
blood drawn at a single blood-letting often exhibits a different appear- 
ance on being received in different vessels. 2 

206. The fact that fibrin exists in larger "proportion in arterial 
than in venous blood, and that its proportional amount is diminished 
when respiration is seriously impeded, seems to point out that it is ex- 
pended in the nourishment of certain of the textures, and that it is 
renewed through the agency of respiration. It might be supposed 
that inflammation increases its quantity by accelerating the circula- 
tion and respiratory movements without adequate expenditure of blood ; 
but although this may be the case to a certain extent, particularly in 
acute rheumatism, it is not a sufficient explanation of the fact, for the 
quantity of fibrin in the blood is not proportioned to the frequency of 
the pulse or of respiration; it is often much increased before these are 

1 Alison's Outlines of Physiology, p. 89. 

2 For much interesting information on the coagulation of the blood, the reader is re- 
ferred to the edition of Hewson's works published by the Sydenham Society, with the 
valuable notes of Mr. Gulliver. 



FIBRIN — NATURE AND ORIGIN — VARIETIES 



157 



materially affected, and in idiopathic fevers it is diminished, although 
the breathing and pulse are commonly accelerated. In fact, various 
circumstances, to be detailed hereafter, render it probable that the in- 
crease of fibrin during inflammation has its origin in the vessels of the 
inflamed part. 

207. The coagulation of fibrin in the blood is favoured by two cir- 
cumstances, the presence of the pale corpuscles (§ 194,) and the for- 
mation of the deutoxide of protein by some oxygenating process ope- 
rating on the albumen: the same circumstances also appear to be 
mainly instrumental in the production of fibrin. Thus, as Dr. Carpenter 
has pointed out, this principle appears in the chyle of the lacteals 
after their passage through the mesenteric glands: it increases in the 
thoracic duct, and becomes still more abundant in the blood of the 
lungs, where there is a free supply of oxygen. It is quite uncertain 
how much in the process is due to vital influence, but there is good 
ground for the belief that some of the change is of a chemical nature. 
The molecular base of the chyle (Gulliver) supplies a congeries of mi- 
nute fat globules which have a tendency to attract around them thin 
films of coagulated albumen (Ascherson,) probably identical mth fibrin 
or deutoxide of protein; and this process takes place in proportion as 
oxygen is supplied from the adjoining red blood discs; thus the mole- 
cular base is converted into single and aggregated granules or pale 
corpuscles of the chyle and blood. The oxygenating process extends 
also to the serum, and converts a small portion of albumen into an 
oxyprotein, still liquid, but ready to take the form of a finely fibril- 
lated solid (fibrin,) under various circumstances already adverted to 
(§ 194.) The perfection of this material, and its susceptibility of 
farther organization, constitute additional characters of fibrin, which 
appear to belong to the class of vital rather than of mere physical 
properties. These will be noticed in the succeeding paragraph ; but 
we may observe here that they are in some degree dependent on the 
quality of the chemical materials, oil and protein, which the chyle and 
blood contain, and the activity of the processes of circulation and res- 
piration, by which these fluids are constantly influenced. A farther 
evidence of the existence of an oxidating process in connexion with an 
abundant production of fibrin may be found in the fact that the bufiy 
coat of inflamed blood contains the tritoxide of protein, a soluble mat- 
ter approaching in nature to gelatine, and which exists also in pus, 
being identical with the principle to which Guterbock gave the term 
pyin. 

208. Fibrin, identical with the buffy coat of the blood, is the ma- 
terial of which new membranes and cicatrices are formed; it is the 
coagulable lymph, indeed, which is the plasma or basis of the construc- 
tive and reparative process. In its capacity for these processes fibrin 
exhibits some modifications of condition constituting degrees of plasti- 
city. Thus in a healthy state (euplasiic) it forms a fine congeries of 
minute fibrils, which, having a high capacity for life, may become or- 
ganized in a high degree, as in the case of false membranes resulting 
from acute inflammation in a healthy'subject. But in many instances 



158 



DISEASES OF THE CONSTITUENTS OP THE BLOOD. 



this high capacity is degraded, and the nutritive material is caco-plastic, 
with fewer and less perfect fibres, and with more corpuscles, giving the 
exudation more opacity, and is susceptible of only a low degree of or- 
ganization, as in the indurations resulting from low or chronic inflam- 
mation, in cirrhosis, gray tubercle, &c. ; or it is aplastic, not organizable 
at all, abounding in degenerating corpuscles with few or no fibrils, as 
in pus, curdy matter, yellow tubercle, &C. 1 It is a fact of great im- 
portance, that the quantity of fibrin in the blood, and the facility with 
which it may be effused, are by no means in proportion to its plasticity, 
or capacity to become organized ; thus it is abundant in the blood, and 
freely effused in the inflammations of scrofulous or tuberculous sub- 
jects, although in such the products of the inflammation, as well as of 
nutrition, are commonly caco-plastic or aplastic. The fibrin of the 
blood or coagulable lymph in these cases is more opaque and less 
elastic than in healthy subjects, and under the microscope presents a 
predominance of corpuscular and granular matter and fat globules, 
and less of the finely defined fibres and regular nuclei, as if it were 
imperfectly elaborated; and it therefore has a tendency to farther de- 
generation. Even the more perfect forms of fibrin or lymph, if in a 
position in which their vitality is not sustained by the completion of 
organization, tend to degenerate, and become disintegrated into an 
amorphous or opaque aplastic substance (Gulliver,) which appears to 
be of the nature of spontaneous fatty degeneration and disintegration, 
and which eventually may undergo a farther change into fatty and cal- 
careous matter, like other aplastic deposits. It is interesting to ob- 
serve that in many of these cases the red corpuscles also are defective 
in quantity (§ 185 ;) and this suggests a probable reason for the imper- 
fection of the plasma. 

209. The coagulation of fibrin is promoted by the contact and mo- 
tion of a rough solid: thus by stirring fresh-drawn blood with a stick, 
the fibrin is caused to adhere in shreds to the stick. The same result 
is exhibited within the body by the deposition of lymph on rough sur- 
faces within the heart and great vessels ("vegetations,") and it is pro- 
bable that the fibrinous concretions called polypi, which are found after 
death in the heart, are formed on its irregular surfaces, when its fail- 
ing motions cause agitation rather than propulsion of the blood. The 
cohesive property of fibrin especially characterizes it, and determines its 
aggregation in patches and films on the surface of membranes ; where 
it is most plastic, it may be drawn into threads or bands. 

210. Remedial measures. — Hyperinosis or excess of fibrin in the 
blood (§ 195) is less rapidly reduced by blood-letting and low diet, than 
is excess of the red corpuscles ; yet these are the chief means employed 
for effecting the object. It would probably be found that purgatives, 

1 The varieties of lymph here described in some measure correspond with those desig- 
nated by Mr. Paget as fibrinous and corpuscular. (Lectures on Surgical Pathology, 1853. 
Yol. I., p. 332.) Mr. Paget lays more stress on the fibrillated texture of the fibrinous 
kind, and the great predominance of the corpuscles in the other; but it seems to me 
very important to keep in view the intermediate variety, which I term caco-plastic, and 
which contains both corpuscles and fibres. This has its difference in its subsequent his- 
tory, and comprehends the three varieties of croupous exudation-matter described by 
Rokitansky. 



FIBRIN — EXCESS — REMEDIES. 



159 



and other agents which much increase the more solid secretions, dimi- 
nish the fibrin. A similar power has been ascribed to mercury, to 
alkaline salts, to iodine, and to antimony: there is a want of experi- 
mental proof in support of the notion ; yet it is favoured by some analo- 
gies, and seems well worthy of farther investigation. 1 The effect of 
salts and alkalies in doing the same thing was probably suggested by 
their property of dissolving fibrin out of the body. 2 

211. According to the views of Dumas and Liebig, subsisting chiefly 
on saccharine, amylaceous, or gelatinous articles of food, mast diminish 
the fibrin and albumen of the blood; and such food is found by experi- 
ence to be the best in inflammatory diseases, in which excess of fibrin is 
a chief element. Is the reputed efficacy of the "cure de raisins," in 
tuberculous disease, connected with the absence of protein compounds 
in the food? Bodily exercise reduces the quantity of fibrin, and may 
be advantageously employed with this view in sthenic plethora and in 
scrofulous hyperinosis, but is not admissible in inflammatory diseases. 
Neither can we suggest any practicable mode of lessening the fibrin 
through lowering the function of respiration, on which its supply seems 
to depend, unless narcotics, which impair many organic functions, have 
some action of this kind. The known utility of opium, aconite, &c, in 
rheumatism and low forms of inflammation, in which excess of fibrin is 
a constant condition, makes this matter deserving of some research. 
Simon mentions one case of phthisis long treated with cod-liver oil, in 
which the fibrin in the blood was reduced in a remarkable degree. 

212. Hypinosis, or deficiency of fibrin (§ 196,) is to be remedied by 
assisting the functions on which the supply of the plastic principle de- 
pends,- — particularly those of digestion, circulation, respiration, and 
assimilation,— and by avoiding its expenditure through too much exer- 
cise or other exhausting processes. If the digestive organs will bear 
them, meat, eggs, bread, and other articles of diet abounding in pro- 
tein compounds, should be taken. The digestive and assimilative 
functions may be roused by stimulants, bitters, quinine, and the mine- 
ral acids ; which, from their power in stopping passive hemorrhage, in 

1 Dr. Karl Popp, who has made elaborate researches on the composition of the blood, 
infers that tartar emetic and nitre, and (in a less degree) calomel, diminish the amount 
of fibrin. Dr. Day in Banking's Abstract, June, 1846. 

2 Mr. James Blake made many experiments by injecting various saline and other fluids 
into the veins, and he has furnished me with a summary of the results found in the blood 
after death. 

The blood was found to be coagulated after the injection of the following matters: — 
Liquor potassre (firmly;) carbonate of potass (firmly;) nitrate of potass (firmly; blood 
scai'let;) nitrate of soda; nitrate of ammonia; nitrate of lime; nitrate of baryta; chlo- 
ride of calcium; chloride of barium ; chloride of strontium; sulphate of magnesia; sul- 
phate of copper; acetate of lead; arsenite of potass; nitric acid (strongly;) narcotin 
(firmly;) tobacco; strychnia (moderately;) conium; hydrocyanic acid; euphorbium; 
and water in large quantity. 

The blood was not coagulated, or imperfectly so, after injection of caustic soda, car- 
bonate of soda, sulphate of soda, ammonia, nitrate of silver, sulphate of zinc, sulphate of 
iron, phosphoric acid, arsenic acid, arsenious acid, oxalic acid, infusion of galls, infusion 
of digitalis, alloxan. 

Some of these results are different from what might have been expected; for instance 
the decided coagulation with potass and its salts, especially nitre, and the fluidity with 
nitrate of silver, sulphate of zinc, infusion of nutgalls, which have been commonly sup- 
posed to possess a coagulating property. 



160 



DISEASES OF THE CONSTITUENTS OF THE BLOOD. 



augmenting the muscular substance and strength, and in causing the 
healing of phagedenic and flabby ulcers, seem to have some more direct 
means of promoting the formation of the plasma of the blood, than by 
their mere operation on the digestive organs. To improve the function 
of respiration, besides attempting to remove or diminish any disease 
from which the respiratory organs may be suffering, the free access of 
pure cool air to the lungs should be secured. The injurious effect of 
exertion is exemplified in the relapses which it often induces in con- 
tinued fever, where defect of fibrin in the blood is a constant condition. 
Fatigue of every kind, and wakefulness, should be carefully avoided, 
and sleep should be obtained by narcotics, if it do not come naturally. 
In case of deficiency of fibrin from the presence of a febriferous or pu- 
trescent poison in the system, it is not to be expected that azotized 
food, rest, or any other means, can remove the deficiency, so long as 
the poison remains in active operation. This poison, by its septic or 
other analogous influence, interferes with the vital process by which 
the fibrin is formed. But no sooner does the influence of the poison 
subside, as evidenced by improvement in the symptoms, than the quan- 
tity of fibrin increases ; and this faster than could be explained by any 
increase of nourishment taken. (Andral and Gavarret.) It would 
seem that the immediate effect of the presence of these poisons is to 
accelerate the decay of the more annualized matters of the blood, which 
thus speedily become resolved into urea or carbonate of ammonia 
(§ 196,) and as we find that such septic changes are retarded by certain 
agents such as nitre (chlorate of potass, strong bitters, alcohol, &c.,) 
out of the body, it does not seem irrational to suppose that similar 
agents may be effectual in counteracting the septic influence within the 
body. The beneficial operation of wine and other alcoholic stimulants, 
of quinine in large doses, and of medicines containing a large amount 
of oxygen, as nitric and nitro-muriatic acids, and chlorate of potass, in 
typhus fevers and other adynamic diseases, is probably connected with 
their antiseptic as well as with their stimulating power. The oxyge- 
nating agents might, perhaps, be more efficacious could they be more 
readily conveyed into the blood without irritating the alimentary canal. 
The administration of oxygen or nitrous oxide by inhalation suggests 
itself as worthy of trial for the same object. 

213. Very little is known of the power of remedies to correct changes 
in the quality of the fibrin of the blood. The increased properties of 
separation (§ 204) and contraction (§ 203) manifested by the fibrin of 
blood in inflammation, are diminished by blood-letting and other anti- 
phlogistic remedies, even more constantly than the excessive proportion 
of fibrin is by the same means ; but they seem to be soon re-conferred 
if the inflammation continues. Thus, although the last cup drawn of 
blood-letting may exhibit none of the buffed and cupped appearance pre- 
sented by the first, yet blood drawn a few hours after often shows it as 
much again. Knowing that this speedy recurrence of morbid proper- 
ties in the blood depends on the influence of the local inflammation, 
we see the necessity of fully using local remedial means, together with 
those that are calculated to operate on the system. 

The beneficial influence of saline medicines in inflammatory diseases 



FIBRIN — DEFECTIVE AND ALTERED— REMEDIES. 



161 



is supposed by Mr. Gulliver to depend on their power to prevent the 
cohesion of the blood corpuscles, and he has hence suggested the free 
application of salt lotions to an inflamed part. The application of salt 
to a recent wound is a well known popular remedy. 

214. Blood-letting and other general antiphlogistic remedies, if they 
do not remove local inflammation, may render its products more inju- 
rious through lowering their plasticity (§ 211,) thus approximating them 
to tuberculous and other aplastic deposits. Thus chronic inflammation 
continuing after the full employment of the antiphlogistic treatment, 
almost surely tends to produce degenerated changes of structure, over 
which remedial art has little power. Hence, therefore, we see how 
desirable it is that inflammations should be removed before they be- 
come chronic ; and when there is a risk of their becoming so, it is an 
indication that we should try to improve the condition of the blood by 
a tonic and nutritive plan of treatment, at the same time that local 
antiphlogistic measures are addressed to the lingering inflammation. 

215. A similar course of tonic treatment is yet more forcibly called 
for in scrofulous, chlorotic, and other cachectic states, in which the 
fibrin, although less abundant than in inflammation, is yet copious in 
proportion to the scanty red corpuscles (§ 212.) Here there is a ten- 
dency to the deposit of imperfect fibrin and granular matter (§ 211,) 
even independently of inflammation ; and, besides means calculated to 
improve the nutrient functions and to raise the character of their pro- 
duct, it may be necessary to use remedies that tend to keep the fibrin 
dissolved, and to prevent its consolidation in aplastic forms. Alkalies 
and iodide of potassium have been supposed to have some claim to the 
power of doing this ; but more efficacy seems to attach to regiminal 
and dietetic influences, such as the exclusion of all food containing solid 
fat and protein matters of the lower class (like casein;) the freshest 
and most sustaining but easily assimilated nutriment should alone be 
allowed, and every available step should be adopted to promote the 
functions of digestion, respiration, capillary circulation, and excretion, 
through due supply of healthy air, and through the employment of ex- 
ercise and frictions of the surface. 



SECTION IX. 

ALBUMEN. 

216. Albumen is an important constituent of the blood, amounting 
in health on an average to about thirty-nine parts in every thousand. 
It was generally supposed to be chiefly useful in affording the material 
from which the plasma (fibrin) is elaborated ; but it was suggested in 
the former edition of this work that some textures may be formed at 
once from the albumen of the serum. This opinion seems now to be 
the prevailing one ; that the more solid tissues as well as the globulin 
and hsematin are formed from the albumen, whilst the fibro-gelatinous 
textures alone are constructed of fibrin. The albumen is farther use- 
11 



162 



DISEASES OF THE CONSTITUENTS OF THE BLOOD. 



ful in giving to the serum a consistency favourable to the process of 
circulation ; it also fits it for the suspension and preservation of the 
red corpuscles, and for blandly sheathing the acrimony of the saline 
constituents. The quantity of solid principles in serum amounts to 
from seventy-two to eighty-eight parts in every thousand during health, 
and of these four-fifths are albumen. It may be generally inferred 
from the specific gravity of the serum, how much albumen it contains: 
this in healthy subjects averages about 1030, but sometimes in disease 
falls as low as 1013. 

217. Excess of albumen exists in most cases of inflammation and 
fever, especially during the more active stages. Its increase is not, 
however, in the same proportion as that of the fibrin. Its relative 
amount is much augmented in epidemic cholera; but this is mainly due 
to the removal of the water of the blood. Albumen is the principle of 
the blood that is least affected in its proportions by disease. Very 
poor living, long continued or copious hemorrhages, and other drains 
on the system, will pretty surely reduce it in common with the other 
animal principles; but good living has less power in raising it above 
the natural standard. In the pallid cacheernia of persons who have 
suffered long under paraplegia, it has been ascertained by MM. Bec- 
querel and Bodier that the albumen is not diminished, but is actually 
in excess, as compared with other solid constituents of the blood: in 
fact it is not the albumen that is absolutely increased, but the red cor- 
puscles diminished, the albumen remaining the same. 

218. The means of reducing an excess of albumen in the blood are 
similar to those capable of diminishing the other animal constituents 
(§ 192, 210,) including depletion, purgatives (especially mercurial,) 
diuretics, (especially alkalies and colchicum,) and low diet, with a 
sparing supply of azotized food. 

219. Deficiency of albumen in the blood is most remarkably met 
with in cases of albuminuria, or disease of the kidney with coagulable 
urine ; and this deficiency precedes the diminution of the red corpuscles, 
which takes place in the advanced stages of this disorder. Dr. Bright 
found the specific gravity of the serum as low as 1013 in a patient 
with albuminuria. (Bright's Reports, vol. i. p. 85.) Dr. Babington 
noticed the specific gravity of the serum, in a case of diabetes, as low 
as 1024 ; and in another as 1027, although that of the blood was higher 
than usual, being 1061. In this case the serum was milky. (Cycl. 
of Anat., &c, Art. " Blood.") Andral observed that the deficiency 
of albumen in the serum of the blood is in exact proportion to its ex- 
cess in the urine. In their later researches, MM. Andral, Gavarret 
and Delafond discovered a remarkable diminution of the albumen in 
dropsical sheep affected with the rot (a watery state of the blood, with 
distomata in the liver.) Sheep in a cachectic state with deficiency of 
red corpuscles in the blood, but without entozoa, or dropsy, had the 
albumen undiminished. It is therefore most probable that the cases 
of cachexia, or anosmia, attended with dropsy, owe this concomitant 
to a defect of albumen in the blood. It is this principle chiefly that 
gives the blood liquor its spissitude, which renders it more fit to pass 



FATTY AND OTHER COMBUSTIVE MATTERS. 



163 



along the vessels, and prevents it from transuding through their walls. 
This deficiency of albumen, therefore, seems to be a chief condition of 
the dropsical diathesis. 

220. We are not acquainted with any other means of increasing al- 
bumen in the blood, where it is deficient, than the adoption of such 
measures as tend to restrain wasting discharges, and to improve the 
general nutrition. The excessive loss of albumen through diseased 
kidneys may be in some cases checked by what may be termed astrin- 
gent diuretics, which are also effectual in arresting hemorrhage from 
the urinary organs. Among these may be mentioned gallic acid, tinc- 
ture of the sesquichloride of iron, benzoate of ammonia, and in some 
cases tincture of cantharides, and oil of turpentine in small doses. In 
various instances, I have used each of these with the result of increasing 
the specific gravity of the urine, yet diminishing the albumen. To 
counterbalance the waste by a liberal supply of nutritious food is 
another obvious indication; and, in addition to the ordinary albuminous 
articles of solid food, a sustaining beverage may be made of raw whites 
of eggs and water, flavoured with sugar and lemon juice. A case is 
mentioned by Simon (Animal Chemistry, by Day, vol. i. p. 280,) illus- 
trative of the extraordinary nutritive properties of cod liver oil in 
phthisis ; the solid constituents of the blood after its use amounted to 
25 per cent. ; the albumen being above 13 of this : the fibrin, usually 
high in phthisis, was below the normal proportion. 



SECTION X. 
FATTY, AND OTHER COMBUSTIVE MATTERS. 

221. The blood in a state of health, contains three distinct kinds 
of fatty matters : — 1. Saponifiable fats composed of the spermaceti- 
like substance called margarine, dissolved in olein, an oily liquid : 2. 
Phosphorized fats, contained principally in the red corpuscle: and 3. 
Cholesterine, a hydro-carbon combined with a minute proportion of 
oxygen, and formed in the liver. The saponifiable fats appear to be 
nutritious principles introduced into the blood by the chyle. The phos- 
phorized fats are probably formed by the blood corpuscles for the 
especial support of the nervous substance. Both these kinds of fatty 
matter are necessary to the early stage of cell production. The cho- 
lesterine seems to be, on the other hand, merely a fuel furnished out 
of excrementitious matter for calorific purposes. It is now known that, 
besides these true fats, the blood also ordinarily contains sugar. This 
principle may always be detected in venous blood, between the liver 
and the lungs, but is destroyed in the lungs by the influence of the air, 
being in these organs converted into water, lactic acid, and finally car- 
bonic acid. No sugar can be found in the blood of the left ventricle. 
Bernard has shown that it is formed by the liver, alike out of azotized 
and unazotized matters. Division of the pneumo-gastric nerve, and 
diseases that exhaust the nervous energy, arrest its production. It is 



164 DISEASES OF THE CONSTITUENTS OF THE BLOOD. 

highly probable that it is destroyed in the lungs for the support of 
animal heat, and that like cholesterine it is a true fuel. Carnivorous 
creatures seem to make most sugar, and the herbivorous most fat, for 
the purposes of combustion. 

222. The oily or fatty matter in the blood is sometimes so much in- 
creased as to give a milky appearance to the serum ; and this increase 
may arise under different circumstances, and from various causes. 
The most common cause is that originally suggested by Haller, and 
lately proved to exist by Dr. Buchanan, the presence of un assimilated 
chyle (§ 211.) The latter physician has ascertained that the serum is 
generally milky in blood drawn four or five hours after a full meal. 
In other instances, this appearance has been observed during illness 
after long fasting, and doubtless then proceeds from the absorption of 
fat from the textures, as supposed by Hewson. In some cases a tur- 
bidity in the serum has been found to depend on the presence of an 
increased number of minute granules of albumen or fibrin, soluble in 
acetic acid, and not affected by ether. (Vogel's Path. Anat. by Dr. 
Day, p. 64. Notes to Hewson's works by Gulliver, p. 85.) Dr. Ba- 
bington met with an extreme degree of milky serum in a case of ad- 
vanced diabetes. This physician states that he has repeatedly found 
milky serum to have a low specific gravity, indicating a deficiency of 
albumen ; and he suggests that the fat might originate in a change in 
the albumen. A similar idea has frequently occurred to myself, when 
considering the remarkable instances of fatty transformation exhibited 
in degenerating textures and deposits, and even in slowly decaying 
animal matter, as in the instance of the production of adipocire. This 
notion has been fully confirmed by the researches of Dr. R. Quain, 
which will be noticed further under the head of Degenerations. The 
fat of the blood seems to vary in nature as well as in proportion ; cho- 
lesterine and margarine are often found on the increase in old and 
cachectic persons, as they also abound in the degenerated tissues and 
cacoplastic deposits of such subjects. 

223. The increase of healthy fat or adipose tissue in the body is 
probably preceded and accompanied by its presence in excess in the 
blood; and the circumstances which promote obesity must operate 
through the composition of this fluid. Of these may be mentioned 
fatty, sweet, and farinaceous food in excess, yet where obvious disorder 
of the digestive organs is not caused ; full living with sedentary habits, 
and especially if combined with the free use of malt liquors ; imperfect 
assimilation, often connected with want of exercise of the respiratory 
organs, either from disease or disuse ; insufficient excretion of bile. 
Exercise tends especially to reduce the fat of the body, probably by 
increasing its combustion in respiration ; the nutrition of muscular tex- 
tures being then augmented by the ' same influence. Thus fat com- 
monly increases at the expense of strength, and is reduced in propor- 
tion as muscular power is restored. Besides the use of as much exercise 
as the strength will bear, exposure to the invigorating influence of pure 
air, and the avoidance of fat and similar articles of food abounding in 
hydro-carbon, some further advantage may be secured for corpulent 
persons by the employment of food and medicines, in which oxygen 



FATTY MATTER — IN EXCESS. 



165 



and azote predominate, as, for instance, nitric acid, chlorate of potass, 
benzoate of ammonia, and some vegetable acids. 

But there is sometimes an increase of fat in the blood without any 
remarkable obesity ; when the fatty matter is formed at the expense 
of albumen and fibrin by a process of degeneration, which affects not 
the blood only, but also the tissues under various circumstances of de- 
graded nutrition and circulation. This fatty cachaemia may slowly 
result from age, debility, or various chronic cachectic diseases which 
impede respiration and excretion ; but I have observed an acute affec- 
tion of the kind to ensue in persons, young and middle-aged, who, with 
very intemperate habits, have endured such privations as to destroy 
all constitutional vigour ; in cases after death, from delirium tremens, 
erysipelas, or some acute attack which proved rapidly fatal, the blood 
and all the textures have been found so abounding in fat as almost to 
countenance the notion that a little more of such a change might ren- 
der the body spontaneously combustible. But in case of disease of the 
liver, the fat in the blood has been found to increase to two or three 
times its ordinary proportion, and it is then chiefly cholesterine. In 
cases of peritonitis and pneumonia also, an excess of fat has frequently 
been found in the blood. A remarkable case of peritonitis is de- 
scribed by Helder, in which the fat attained the extraordinary propor- 
tion of 50 in 1000 of serum: the red corpuscles were much below the 
usual standard (Dr. Day's Note to Simon's Animal Chemistry, vol. i. 
p. 271.) It is probable that in many of these instances the excess of 
fat is the result of its rapid absorption from the adipose tissue during 
the disturbance of the acute attack ; but others are the result of an 
undue formation of fat, or of its insufficient combustion by the respiratory 
process. 

224. Defect of fat in the blood occurs in connexion with continued 
inanition and emaciation, especially in typhoid fevers and malignant 
diseases. In scrofulous emaciation the fat in the blood is not always 
lessened; sometimes it is increased; apparently in connexion with the 
fatty transformations which take place in the deposits, and sometimes 
in organs, as in the liver. It would be interesting to know the state 
of the blood in those cases in which large quantities of fatty matter 
are discharged from the intestinal canal. 

Deficiency of fat in the blood is to be obviated by the administration 
of such oleaginous articles as the stomach will bear (such as cod liver 
oil, cream, bacon, mutton suet diffused in milk, &c.,) and also by oily 
inunction and frictions of the surface. This subject will come under 
our notice in connexion with atrophy. But it may be mentioned here 
that a knowledge of the condition in which the fatty principle best 
assists in nutrition in health may be useful in guiding us in the selec- 
tion of the oleaginous articles of food or medicine best suited to supply 
the deficiency. Thus the more fluid fats are preferable to the solid, 
from their being more easily absorbed and as supplying finer molecules 
for the chyle. Again, some oils are more readily saponified than others ; 
in this respect there is an advantage in cod liver oil, which, like the 
fat of bacon, readily saponifies or forms an emulsion with carbonated 
alkalies, which is not the case with oils or fat in general. In case of 



166 



CONSTITUENTS OF THE BLOOD. 



paralysis or great depression of the nervous power, it may be useful to 
give phosphorated oil, with the object of supplying the materials by 
which the nervous function is sustained. From T V th *° 2V n °f a g ra i n 
of phosphorus may be given in a teaspoonful of almond or cod liver 
oil. A diet abounding in milk and cream is also calculated to supply 
both oil and phosphate of lime to the blood, and has often proved be- 
neficial in cases of atrophy; but it is remarkable how readily in some 
cases it arrests the secretion of bile. 



SECTION XI. 
SALINE AND MINERAL MATTERS. 

225. Healthy blood contains, upon an average, 8 parts in 1000 of 
mineral substances (exclusive of the iron of the red corpuscles ;) these 
are principally in the condition of salts, — chlorides, carbonates, phos- 
phates and sulphates of soda, potash, magnesia, and lime. The chlo- 
ride of sodium is singularly constant in its proportions, — the phos- 
phates in larger amount in carnivorous animals, and the carbonates in 
herbivora. Rose thinks that the phosphates are only formed at the 
instance of the destructive oxidation of the phosphorized fats, the phos- 
phoric acid then taking the alkaline bases from carbonic, and the or- 
ganic, acids. He holds a similar view with regard to sulphur, iron, 
sodium, potassium, &c, which, existing in the blood and in other ani- 
mal constituents in an unoxidized state, take an important part in their 
metamorphoses. 

The saline matter dissolved in the blood tends to preserve the form 
of the red particles and the fluidity of the fibrin. The phosphate of 
soda dissolved in the serum enables that fluid to take up twice its volume 
of carbonic acid (as much again as water can absorb.) Phosphate of pot- 
ash is devoid of this important property. It is most probable that the 
phosphate of potash and chloride of sodium in the blood are constantly 
effecting each other's decomposition, phosphate of soda being found to 
render the serum powerfully absorbent of carbonic acid, and the potash 
being employed in the construction of muscular substance. Potash is 
as essential to the composition of muscular tissue as phosphorus is to 
that of nervous matter. The earthy salts supply inorganic ingredients 
to the various tissues; and especially the phosphate of lime, which 
appears to be essential to the formation of rudimentary cells. Yogel 
states that the salts of the blood are in excess in scurvy, and cause the 
hemorrhagic disposition in that disease; but this does not accord with 
what has been observed in this country (§ 196.) He also thinks that 
the same influence renders the red corpuscles granular or puckered at 
their margin by withdrawing some of their fluid contents. Such a 
condition of the red corpuscles, as well as an excess of saline matter, 
was present in the blood of a boy suffering from purpura, who was 
under my care a few years since. 

There can be little doubt that the thirst induced by the use of salt 



SALINE MATTER — DEFICIENT. 



167 



food is connected with the excess of saline matter then thrown into the 
blood, which causes a shrinking in the red corpuscles, and makes them 
attract, by endosmose, fluid from the textures and surfaces, wherever 
they come; this constantly setting up fresh demands for liquid, pro- 
duces the sensation that prompts drinking as the natural means of fur- 
nishing the supply. 

226. Diminution of the ordinary quantity of saline matter in the 
blood has been said by Dr. Stevens to take place in yellow fever and 
in other pestilential diseases, and to cause then so dark and grumous 
a state of the blood, that free exposure to air will not render it florid, 
as it generally does. This has been distinctly ascertained to be the 
case with regard to malignant cholera, by Dr. O'Shaughnessy ; and the 
defect of saline matter and water seems to be the immediate cause of 
the obstructed circulation, lividity, and collapse, so remarkable in the 
advanced stage of that terrible disease. Dr. Mackintosh found in 
some extreme cases that the blood was extensively coagulated in the 
heart and large vessels. There can be no doubt, therefore, that in 
these circumstances the blood coagulates in the vessels for want of sa- 
line matter, and that the red corpuscles become partially dissolved and 
altered. Hence the temporary efficacy of injection of saline solutions 
into the veins of cholera patients ; it seems at once to renew circula- 
tion, respiration, warmth, and other vital functions, as if the saline solu- 
tion were the only thing needed. But the defect in the blood is a result 
of the excessive evacuations of serum from the stomach and bowels 
which are the effect of the action of the poison ; and if these go on, the 
good influence of saline injections is soon exhausted. 1 

227. The researches of Andral scarcely support the notion enter- 
tained by Dr. Stevens, that the salts of the blood are deficient in typhus 
fever. If saline medicines are useful in common continued fevers, it is a 
question whether it is in consequence of their supplying what is deficient, 

1 It has been stated that in many cases of malignant cholera there is little or no dis- 
charge from the stomach and bowels, and yet the symptoms of collapse proceed as usual ; 
but so far as my limited experience has permitted me to judge, it appears to me that there 
is a relation between these symptoms and the loss of serum from the intestinal surface. 
In the worst cases, where the prostration is most complete, this serum is not evacuated, 
but distends the intestines, and on palpitation may be felt, giving the feeling of liquid 
weight in the abdomen, which is remarkably dull on percussion. Doubtless the forcible 
and speedy discharge of this secretion is an evidence of a strong reaction, endeavouring 
to rid the system of the poison; and I quite agree with those who object to the practice 
of beginning the treatment with astringents and opium. To aid and equalize the expul- 
sory effort by remedies which promote the biliary and renal, as well as the intestinal se- 
cretions, seems to be the first indication. But it may soon be necessary to moderate the 
excessive discharge and allay severe pain and irritation, sometimes by moderate but fre- 
quent doses of astringents and narcotics, but always by ice and cold beverages internally, 
and by heat, stimulants and frictions very freely and assiduously applied to the surface 
and extremities. Whether this treatment shall prove successful or not, will depend on 
the intensity of the poison and the power of the constitution to resist its influence. At the 
outbreak of the epidemic the poison is usually so strong that the larger proportion die 
in spite of all treatment; as the epidemic declines, the treatment proves more successful, 
and the plurality of cases recover. It is during the balance between the contending 
forces that saline injections into the veins may save life — not by curing the disease, but 
by counteracting its fatal effects on the blood, so that longer time is gained. This mea- 
sure therefore should not supersede others, which are indicated by the symptoms of the 
case. 



168 



CONSTITUENTS OF THE BLOOD. 



or whether it may not rather be through the augmentation of torpid 
secretion (§ 171,) and the removal or counteraction of septic influences 
present in the system (§ 98, 105.) Certain it is that not only in fever- 
ish affections, but in that very numerous class in which the urine is 
scanty, high-coloured, highly acid, and often depositing a sediment of 
lithates or oxalates, and frequently the coated tongue, thirst, disturbed 
appetite, and depraved secretions, show the unhealthy condition of the 
alimentary canal. Saline solutions, especially in the effervescing state, 
are most beneficial and grateful, and often correct what is disordered 
in the secretions. In prescribing these salines, however, it is right to 
bear in mind the influence which they may have on the composition of 
the blood, and so to combine the alkalies that neither shall have a dis- 
turbing preponderance. With this view soda and potass should both be 
given, with the addition of ammonia if the dryness of the skin or the 
weak state of the circulation should indicate it. This method of com- 
bining the alkalies much increases the utility of saline medicines ; but 
if exhibited long they have a tendency to weaken the digestive powers 
and to cause flatulence and distention of the abdomen. This may 
often be counteracted by the addition of a minute proportion of a salt 
of iron, which endows the medicine with a tonic property. 

It is stated by Henle that a diminution of saline matter takes place 
in the blood of inflamed blood-vessels, but this statement seems to be 
no more than an assumption made in aid of his favourite explanation 
of the obstruction in inflammation. 



SECTION XII. 
WATER. 

228. The average proportion of water in healthy blood may be stated 
at about 79 per cent. It is obvious from what has been already said, 
that this proportion increases as that of the organic constituents de- 
creases. Thus, after excessive hemorrhage, and in chlorosis and other 
cachectic states attended with anemia, the blood is more watery than 
usual. The effect of this state of the blood is a tendency to dropsical 
effusions and fluxes, besides the consequences which result directly 
from the relative deficiency of the other constituents of the blood. 

229. I have before suggested (§ 187) the question for consideration, 
whether the serious functional disturbance sometimes following the 
ingestion of very large quantities of liquid, particularly after exertion, 
when absorption is active, may not in some degree arise from the too 
copious and sudden addition of water to the blood. Certainly tempo- 
rary plethora, with palpitation, and feeling of oppression or dyspnoea, 
often results from the too free ingurgitation of liquid, and is not removed 
until perspiration, or a free flow of urine, relieves the overloaded vessels. 
These effects are most distinctly observed when some structural disease 
of the organs of circulation or respiration incapacitates them for meet- 
ing the increased task. Hence the aggravation that occurs in the 



WATER — DEFICIENCY — WATER CURE — EXCESS — DRY CURE. 169 

symptoms of disease of the heart and lungs, when too much drink is 
taken. The colliquative sweats in phthisis seem to arise from a similar 
cause, and may often be relieved by a judicious reduction in the quan- 
tity of liquid food. 

230. Deficiency of water in the blood is exemplified in epidemic cho- 
lera, in which the specific gravity of the serum has been found as high 
as 1045 (Lecanu;) this implies a reduction of the ordinary quantity of 
water to the extent of nearly one-half. Some diminution probably 
takes place in other diseases, attended by profuse watery discharges, 
such as diarrhoea, diabetes, and excessive sweating. In these cases, 
the smallness of the pulse, and sometimes the shrunk appearance of 
the surface from the undistended state of the vessels, indicate the di- 
minished bulk of the circulating fluid ; and thirst pretty constantly points 
out the mode which nature suggests as a remedy for the defect. Ex- 
posure to heat, especially if long continued, and prolonged violent ex- 
ercise, expend the water of the blood, and cause the feeling of thirst 
which prompts to its restoration. Long continued abstinence from 
drink has a similar effect. 

It has been already mentioned, that the extraordinary decrease of 
the water of the blood in malignant cholera renders that liquid so thick 
that it cannot circulate freely, and that this change is the chief cause 
of the cessation of the pulse, lividity, and other signs of obstructed cir- 
culation. No such effect is, however, known to accompany any of the 
other states where water is deficient. The influence of heat and pro- 
longed exertion is complex, and therefore not referable to this princi- 
ple only. Abstinence from drink for two or three days induces languor, 
small and easily accelerated pulse, a somewhat dry and pasty state of 
the mouth, and scantiness and turbidity of the urine, but little derange- 
ment of other functions. The digestive process, which might be ex- 
pected to suffer, in some cases at least, shows no symptoms of disorder. 

231. We thus have the power of increasing or diminishing the quan- 
tity of water in the blood by increasing or diminishing the quantity 
of liquid drunk ; and these expedients may be usefully employed in 
cases such as are mentioned above. But these expedients also furnish 
us with therapeutic agents of more extensive power when they are em- 
ployed in extremes. Drinking large quantities of water may excite 
the whole vascular system and its connected secreting organs, and may, 
in a salutary manner, wash out of the blood various effete or noxious 
matters; it is in this way that the " water cure" sometimes produces 
its beneficial effects. The free use of liquid ingesta is supposed, by 
Prout, to prevent the formation of lithic acid, or, according to Liebig's 
views, it facilitates the conversion of lithic acid into urea. From the 
experiments of Dr. Bocker (Brit, and For. Med. Bev., Oct., 1854, p. 
393,) it is proved that large draughts of water reduce the weight of the 
body by accelerating the metamorphosis of tissue and in increasing its 
elimination through the kidneys and bowels. On the other hand, a 
total abstinence from drink for two or three days is an effectual mode 
of stopping fluxes, and of relieving catarrhal inflammations and con- 
gestions. Either plan exerts an alterative operation on the circulation 
and secretions, which, if more studied, may perhaps be turned to good 



170 



ELEMENTARY CHANGES IX THE BLOOD. 



account in the treatment of many diseases. But their injurious effects 
should be held in mind: thus the "water cure " is known to produce 
an eruption of boils on different parts of the body; and these, although 
considered by the advocates of this system as symptoms of a salutary 
crisis, are a serious and sometimes dangerous evil; and most probably 
proceed from an injury done to the blood and the nutritive function by 
an excess of water, which tends to injure the red corpuscles, and thus 
to spoil the blood, and to increase the waste of the textures. Again, 
the " dry-cure," by abstinence from liquids, may cause faintness and 
exhaustion in weakly persons, and might be hurtful in those subject to 
urinary gravel. 



SECTION XIII. 
CHANGES IN THE BLOOD BY RESPIRATION. 

232. The process by which venous blood is made arterial, and ren- 
dered fit for its purpose of maintaining the life and functions of the 
several parts of the body, is liable to be variously modified ; and the 
differences in the state of the blood thence resulting form important 
elements of disease. 

The conversion of venous into arterial blood is effected by the ab- 
sorption of oxygen, and the removal of some carbonic acid and water ; 
and a slight increase in the proportional amount of fibrin is the constant 
accompaniment of these changes. Each of these several parts of the 
process is probably concerned in giving to arterial blood its fitness for 
its function; the absorbed oxygen, by its affinity for the hydrogen and 
carbon of the blood and textures, aiding in those processes by which 
these are renovated in function as well as in structure, superfluous fat 
and other combustible matters consumed, and heat evolved; the re- 
moval of the carbonic acid being the excretion of a noxious matter; 
and the renewal of the fibrin supplying the loss of that plasma occa- 
sioned by the waste of the fibrous and membranous structures. 

233. It is doubtful whether the respiratory changes are ever carried 
on in excess ; for, by an admirable adaptation, the activity of respira- 
tion is proportioned to the rapidity of the circulation and the corre- 
sponding need of alteration in the blood. 1 Thus exercise accelerates 

1 It seems to me that Professor Liebig has given too mechanical a view of the change 
of the blood in respiration. He appears to consider the increased arterialization, during 
exercise and on exposure to cold, to be a necessary consequence of the greater amount 
of air inhaled, in one case in consequence of accelerated movements of the chest, in the 
other in consequence of the greater density of the cold air. But if the extent of the 
changes wrought by respiration were in exact proportion to the quantity of oxygen re- 
ceived into the lungs, how easy would it be to increase them (and thereby animal heat 
also) by voluntarily augmenting the respiratory movements. I cannot but think that 
the proportion of oxygen absorbed, and of carbonic acid expired, depends more on the 
condition of the blood brought to the lungs, and that the respiratory movements are re- 
gulated by this. Thus the increased oxygenation of the blood is a consequence of greater 
changes previously wrought in the blood itself, and not a mere result of a fuller access 
of air. In confirmation of this view I may mention an experiment which any one can 
repeat; if a succession of moderately deep and quick respirations be performed during 
several minutes at a pretty low temperature, the effect is to cause feelings of chilliness 



CHANGES BY RESPIRATION — INCREASED. 



171 



the circulation and changes of the blood, and also augments the breath- 
ing movements. In fevers the frequency of the pulse and of respiration 
is increased; but the muscular strength being much impaired, it is 
doubtful whether the rapidity of the circulation or the real amount of 
the respiratory operations is augmented in the same proportion. It 
has been said, that in acute rheumatism the circulation and respiration 
are too active for the wants of the system, and that the blood reaches 
the veins without having wholly lost its arterial character. If this be 
a correct observation, the Iryper-arterialization of the blood may per- 
haps account for the unusual quantity of fibrin which is present in the 
disease. I must, however, remark that I have found the excess of 
fibrin in cases in which there had been no remarkable acceleration of 
the pulse or respiration. We shall see hereafter that the increase of 
fibrin is connected rather with the local inflammation than with the 
fever. 

234. From the experiments of the late Mr. Broughton, it appears 
that when animals are confined in oxygen gas, they die comatose in 
the course of a few hours : the respiration first ceases, whilst the heart 
continues to beat with vigour, and the blood, even in the veins, is quite 
florid: the blood also presents the arterial character of very speedy 
coagulation. It appears, then, that excess of oxygen injures first the 
nervous function (§ 154 ;) but whether it does so by exhausting it 
through previous excitement, or by the increased coagulability of the 
blood, or by the excessive production of carbonic acid, has not been 
decided. The last named mode of explanation is the most consistent 
with the related phenomena : it can scarcely be doubted that an increase 
of oxygen in the blood must augment the production of carbonic acid ; 
and that this latter agent may asphyxiate independently of the exclu- 
sion of oxygen, appears from an experiment by Rolando: he found that 
the air-tube of one lung of the land tortoise may be tied without ma- 
terially injuring the animal, but that if one lung were supplied with 
carbonic acid gas whilst the other received air, the animal died in a 
few^hours. (Carpenter's Human Physiology, p. 542.) 

235. Defect of change in the blood by respiration is a common and 
important cause of disease, and constitutes a chief feature in affections 
of the respiratory apparatus. Being the essence of the special disease 
asphyxia or apncea, its minute consideration belongs to special patho- 
logy, and we shall here only describe it in its more general characters. 

The amount of mischief arising from defective respiration varies 
greatly according to the sudden or the gradual supervention of the 
evil. An acute attack of disorder in the organs of respiration may 
prove distressing, and even fatal, although the impediment to the 
breathing is much smaller than that caused in some chronic diseases, 
where nevertheless, in consequence of the gradual nature of the in- 
fringement, the mischief is scarcely perceived. Thus, too, patients 

and faintness rather than of increased warmth and energy; it is like extinguishing a fire 
by overblowing it. It appears certain, however, that moderate cold to the surface of the 
body, as by cold bathing, increases the respiratory process; for it not onry renders the 
respiration more frequent, but it causes more urea to pass off in the urine, which is an 
evidence of accelerated oxidation. 



172 



ELEMENTARY CHANGES IN THE BLOOD 



affected with extensive emphysema of the lungs are habituated to an 
imperfect state of respiration, which is shown by a constant lividity of 
the lips arid cheek; such an appearance would be a sign of approach- 
ing death in other persons. The cause of this difference is not merely 
the general fact that sudden changes produce more effect than slow 
changes; it lies chiefly in this; — that the importance of the respiratory 
function varies under different circumstances. When the several parts 
of the body, especially the muscular organs, are in a state of full ac- 
tivity, more breath is needed to remove from the blood the noxious ef- 
. fete matter which is always produced by functional exercise. Hence 
in such a condition (which is that of healthy action) the respiratory 
process cannot be abridged without serious disorder. This disorder is 
first obvious in the increasing sense of oppression and suffocation which 
the want of breath causes, and which excites forcible exertions to 
breathe. If these exertions still fail to duly aerate the blood, it partly 
is arrested in the lungs, right compartments of the heart, and veins, 
and partly passes in an imperfectly arterial state to the left side of 
the heart, and to the arteries. 

236. The phenomena of asphyxia are thus compounded of— -1, accu- 
mulation of blood in the venous system ; 2, diminution of blood in the 
arterial system; and 3, deficiency of oxygen and excess of carbonic 
acid in the blood. These several conditions cause injury to the vital 
functions, both by the want of a due supply of blood, and by the bad 
quality of that blood, which last is injurious, — negatively through want 
of oxygen, the proper exciting agent, and positively from excess of 
carbonic acid and other excrementitious matters, which are sedative 
influences. The symptoms induced are also of two classes — 1, those 
implying failure of function, such as muscular debility, feeble action 
of the heart, pallor and coldness of the surface and extremities, and 
loss of the sensory and mental faculties ; and 2, those arising from con- 
gestion and the noxious influence of the black blood, such as palpita- 
tion, flashes in the eyes, noises in the ears, delirium, muscular spasms, 
stupor, &c. Either of these sets of symptoms may predominate in 
different cases, and hence a variety in the phenomena of asphyxia, 
which has not been sufficiently noticed by writers on the subject. 

237. But we have also to notice the other mode in which the changes 
in the blood effected by respiration may become defective, that occur- 
ring gradually, or when the vital functions are in a languid state. It 
is well known that hybernating animals scarcely breathe at all, and 
yet live ; this is obviously because their vital functions are reduced to 
an extremely torpid state. So, too, animals newly born will bear the 
privation of air for a much longer period than those which are older ; 
it has been supposed that in adults failure of the heart's action by 
syncope retards the operation of asphyxiating causes. (Dr. Carpenter, 
on Asphyxia, Library of Med., vol. 3.) Although a man cannot be 
reduced to the torpidity of hybernation, yet it is certain that he may 
be brought to bear a defect in the respiratory blood-changes, which 
would be fatal in a few minutes under common circumstances. This 
is seen when the defect is congenital, as in those affected with malfor- 
mations of the heart causing cyanosis ; and it is also seen where the 
defect is very gradually induced, as in emphysema of the lungs. 



BY RESPIRATION — -DEFECTIVE — APNCEA — HYBERNATION. 173 



238. In cases of cyanosis, (the blue disease, in which, from malfor- 
mation of the heart, some venous blood passes into the arteries,) we 
have the opportunity of observing the more essential effects of defective 
arterialization of the blood. Individuals thus affected are in a lower 
scale of animation. The processes of nutrition and secretion seem to 
go on pretty well, but the muscular power is low; slight exertions 
bring on symptoms of faintness, palpitation, suffocation, or insensibilit}^ ; 
the animal heat is lower than is natural, and there is greater suffering 
from the influence of cold. In short, all the powers of body and mind 
are slender, and are easily disordered by circumstances that tax their 
activity. In the few that reach mature age, there is no sexual pas- 
sion, which seems to be a happy provision against the chance of per- 
petuating a race of imperfect beings — human reptiles. The subjects 
of cyanosis are said to be very liable to hemorrhages, and when these 
occur spontaneously, or from accident, it is very difficult to stop them. 
This must be ascribed to the deficiency of fibrin which we already 
stated to occur where the changes of the blood by respiration are im- 
perfect (§ 196.) The same peculiarity occurs in the foetus. 

239. In connexion with the scantiness of fibrin in the blood, when 
the respiratory changes are defective, we must notice that the exces- 
sive deposition of fat, which often occurs, agrees very well with Lie- 
big's idea that respiration directly consumes the oily parts of the blood ; 
the respiration being defective, the fat accumulates (§ 224.) 

Liebig appears to suppose that the poisonous action of hydrocyanic 
acid and sulphuretted hydrogen is due to their rendering the iron of 
the red corpuscles of the blood incapable of absorbing oxygen from the 
air, and becoming thus the medium of its transfer to the blood and 
tissues: but to this hypothesis it may be objected that the blood of an 
animal poisoned with hydrocyanic acid exhibits the usual changes on 
exposure to the air. Sulphuretted hydrogen does seem permanently 
to injure the composition of the blood, but it does not affect the red 
corpuscles merely ; for it renders the blood fluid, as well as of a dirty 
red colour. It does not seem possible now to deny the fibrin and al- 
bumen a share in the absorption of oxygen, as well as the chief place 
in furnishing the material on which that oxygen afterwards acts. 1 

240. Remedial measures.— Besides the obvious measure of endea- 
vouring to restore the respiratory function where it is defective, the 
view taken above of the mode in which the defect is hurtful (§ 236) 
suggests means by which its injurious effect may be diminished. What- 
ever lowers the activity of the vital functions will often give relief. 
Complete rest of body and mind; warmth to the surface and extremi- 
ties, whilst air is supplied cool and fresh to the face and air-passages ; 
and the employment of various sedatives, which reduce the circulation 
and other vital functions to a lower standard, (or, in the language of 

1 The opinion thus expressed in the former edition corresponds with the .views of 
Mulder, Scherer, and others, subsequently published ; but these chemists seem to me to 
go to the opposite extreme in assigning to the protein the chief share in the process of 
absorbing oxygen. Many facts 183, 188,) combine to prove that the red corpuscles 
are pre-eminent in their power to absorb and convey oxygen, although it is by no means 
certain by what chemical property they do so. 



174 



ELEMENTARY CHANGES IN THE BLOOD 



Laennec, diminish the want of breath,) such as digitalis, conium, hyos- 
cyamus, &c, should all be adopted. Other medicines, such as ether, 
belladonna, stramonium, lobelia, &c, sometimes relieve dyspnoea, but 
they probably act in another way by removing spasm or other me- 
chanical impediments to respiration. 

241. In extreme cases bordering on asphyxia, the enfeebled circula- 
tion may require stimulants (§ 235,) and the engorgement of the venous 
system may call for depletion at the same time ; in different instances 
one or the other of these conditions may most need attention ; some- 
times both must be attended to in the same case. It appears from the 
researches of Chossat, Erichsen, and others, that no stimulant is so 
generally useful as that of heat to the whole body ; and in the ex- 
perience of the officers of the Royal Humane Society, the warm bath 
has been found the most useful remedy in restoring animation sus- 
pended by submersion. Warm frictions and stimulating applications 
are likewise very serviceable in exciting the failing circulation. 

242. Experience has not yet furnished us with any other means of 
arterializing the blood than the process of respiration. This process 
may in some cases be carried on artificially, either by mechanical means, 
such as the inflation of the lungs, or by electricity applied to the mus- 
cles of respiration, (the diaphragm and abdominal muscles alternately ;) 
or it may be helped by bronchotomy; or by chemical means, such as 
the supply of pure oxygen or nitrous oxide. Whether the internal ad- 
ministration, or the injection into the veins, of saline and other mat- 
ters containing much oxygen in loose combination, such as the chlorates, 
nitrates, and some peroxides, may not be made to aid in some degree 
in compensating for defective respiration, is worthy of consideration 
and more extensive trial than it has yet received. If these matters 
could furnish oxygen to the blood, they would yet leave unaccomplished 
the other office of respiration, the removal of carbonic acid. Might 
this be accomplished by the administration of free alkalies? In some 
cases of asphyxia by carbonic acid gas, I have thought that some be- 
nefit in the progress towards recovery was derived from the use of li- 
quor potassre combined with chlorate of potash. Possibly warm baths 
containing these ingredients might be made serviceable, as well as 
friction of the surface of the body with these solutions and those of 
similar matters. 

243. The congested state of most organs, which occurs when the 
respiratory process is imperfect, necessitates the employment of re- 
medies suitable to the removal of this condition ; it is from a disregard 
of this consequence of imperfect breathing that many fall victims to 
the secondary effects of apncea. The lungs, the brain, and the liver 
suffer from it most. The best remedies in these cases are mercurial 
and other medicines which act freely on the secretions (§ 173.) Pro- 
bably these act in part by making the liver assist the lungs in their 
office of decarbonizing the blood. The speedy relief afforded to dys- 
pnoea by a bilious diarrhoea has several times seemed to me to coun- 
tenance this notion. 

244. When the respiratory changes of the blood are reduced by dis- 
ease within a narrower sphere, it becomes an object not to increase the 



BY SECRETION — URINE — DEFECTIVE. 



175 



hydrocarbon of the blood by the use of food with much fat or by the 
employment of spirituous liquors; lean meat and other fibrinous arti- 
cles, with farinacea and fruit abounding in vegetable acids, should 
form the chief sustenance. 



SECTION XIV. 
CHANGES IN THE BLOOD BY SECRETION. 

245. Having already noticed this subject under the head of diseased 
secretion (§ 158,) it will be unnecessary to dwell long on it here ; but 
it will be useful to glance at the changes which result from the re- 
tention in the blood of matter which ought to be excreted, and which 
gives rise to various important disorders. 

The most remarkable instance of disorder arising in this manner is 
exhibited in defective secretion of urine (§ 70, 170.) The extreme 
power of this as a cause of disease was shown in experiments first per- 
formed by Prevost and Dumas, in which the kidneys of animals were 
extirpated. On the third day after the operation, there came on vo- 
miting, diarrhoea of a copious brown liquid; 1 fever, with heat sometimes 
as high as 110°, and at other times as low as 92° ; pulse very small 
and frequent ; breathing laboured : death ensued from the fifth to the 
ninth day. After death there were found effusions of serum in the 
brain, copious mucus in the bronchi, and bilious fluid and feces in the 
intestines. The liver appeared inflamed (?) and the urinary bladder 
much contracted. The blood was more watery than is natural (§ 222,) 
and was found to contain urea to a large amount: thus five ounces of 
blood of a dog yield twenty grains of urea; and two ounces of cat's 
blood, ten grains. 

246. The symptoms induced in defective secretion of urine resulting 
from degenerative disease of the kidneys are very similar to those just 
mentioned, but more diversified, partly from the defect taking place 
in different degrees as to amount and time. Thus, in acute cases of 
albuminuria, or acute aggravations of old ones, there may be epileptic 
convulsions, low delirium, and other typhoid symptoms passing into 
coma (§ 129,) suffocative catarrh, obstinate vomiting, diarrhoea, or in- 
flammatory effusions in the serous cavities, any of which may end in 
death. In slower cases, cachexia and dropsy may ensue more gradu- 
ally, as the blood and solid structures become altered. All these effects 
may be traced to excrementitious matters being retained in the blood, 
and especially urea, which has in very many instances been detected 
in considerable quantities: when in the greatest amount, acting on 
the nervous system as a narcotic poison (§ 129;) when in smaller, 
operating as an irritant, and inducing low inflammation in various 

1 From the researches of Bernard and Barreswil it appears that the matter excreted 
from the intestines contains a quantity of ammoniacal salt which results from the elimi- 
nation of urea from their surface. — Dr. Day's Lectures on Animal Chemistry, Med. Gaz., 
Sept., 1847. 



176 



ELEMENTARY CHANGES IN THE BLOOD 



membranes and viscera; and in still lower degree, causing sundry func- 
tional disorders, fluxes, and dropsies, impoverishing the blood, and in- 
ducing degeneration of certain textures (§ 212.) It has been before 
mentioned (§ 170) that Professor Frerichs ascribes the worst effects of 
urea in the blood (coma, convulsions, &c.) to its being converted into 
carbonate of ammonia by a farther fermentative process ; and this 
notion is rendered more probable by the fact that urea is sometimes 
present to a considerable amount in the blood without any serious 
symptoms. But the tendency to local inflammations and effusions, 
and gradual degeneration of the blood and textures probably depend 
on the imperfect elimination of urinous matter from the circulating 
fluid. 1 It has been already mentioned that the blood in albuminuria 
loses its proper amount of red corpuscles (§ 185) and albumen (§ 222,) 
and the diminution of these assists in accounting for the weakness, 
dropsy, and degenerations which commonly ensue in protracted cases. 
The several results now enumerated may be differently presented in 
different cases, and the treatment should be varied accordingly. 

247. The effects of a defective secretion of bile have not been so 
accurately determined. The presence of bile in the blood is often ob- 
vious in the yellow colour of the serum and fibrin, which changes to 
the characteristic green on the addition of nitric acid ; in such cases, 
analysis has discovered, besides the bilin and the biliphsein, an increase 
of fatty matter to double or treble the ordinary proportion. In several 
cases of fatal jaundice connected with structural disease of the liver, I 
have observed extensive ecchymoses on the legs, which were probably 
due to the destructive influence exerted by bile on the red corpuscles 
(§ 187 ;) and I have already stated (§ 171,) that in most of the cases 
of purpura which I have seen, there has been imperfect action of the 
liver, the most effectual treatment being accordingly by the use of me-- 
dicines which this circumstance suggested. The presence of bile in the 
blood, although sometimes causing tingling, pruritus, and cutaneous 
eruptions, does not appear to produce so much local irritation and in- 
flammation, or change of the blood constituents and general dropsy, as 
that of urea does. Bile seems to be effete and noxious matter rendered 
comparatively harmless that it may be again absorbed into the blood 
and employed as a fuel in support of the animal temperature, before 
it is finally expelled from the system. Still it appears from very pro- 
longed cases of diseases of the liver with or without jaundice, in which 
the dropsy is not local merely (ascites,) but general (anasarca and 
hydrothorax,) that the blood at last is impoverished, and that the whole 
body becomes cachectic. Andral found that in dropsical sheep, with flukes 
in the liver, the albumen, as well as the red corpuscles of blood, was 
diminished. Symptoms of giddiness, faintness, drowsiness, and nausea 
often occur in connexion with imperfect action of the liver, together 
constituting what is commonly designated by the term bilious attack. 
and these are relieved by medicines which promote a free flow of bile : 
but whether all this is caused by retention of the excrementitious mat- 

1 The diminution of the salts in the urine, particularly the chlorides, noticed by seve- 
ral observers to occur in various inflammatory diseases, is probably connected with a 
corresponding increase in the diseased parts. 



BY SECRETION — DEFECTIVE — URiEMIA- 



. — REMEDIES. 



177 



ter in the blood, or by the sympathy (§ 152) of the brain and heart 
with the stomach and liver, is uncertain; but in severe cases the symp- 
toms are sometimes alarming from the depression of the heart's action, 
feeling of death-like oppression, and overwhelming vertigo ; a very acid 
fluid is often vomited, and subsequently bile in quantities; and not 
unfrequently a very dark-coloured bile passes downward with great 
relief to all the symptoms. 

218. The remedial means to be directed against an accumulation of 
the urinous constituents in the blood comprise chiefly medicines which 
increase the secretions (eiiminants,) and those which counteract the 
pernicious influence of the excrementitious matter on the various func- 
tions including that of nutrition. Of eliminant remedies, doubtless, 
diuretics, which may restore the function of the failing secretory organ, 
are most called for; but it often happens that the kidneys are diseased, 
and will not answer to their usual stimuli, as it occurs in inflammation, 
extensive congestion, and degeneration of these glands. Under these 
circumstances, purgatives, especially those that excite a copious watery 
discharge, and diaphoretics, may give relief, by effecting the purifica- 
tion of the blood by other emunctories ; and in case of coma, convul- 
sions, or extensive dropsy from uremia, these remedies, if freely and 
promptly used, often succeed in averting a fatal result. In this way a 
dose or two of calomel, followed by repeated saline purgatives, may 
give seasonable relief. Saline purgatives and diuretics are generally 
safer and more efficacious than others; but croton oil, jalap, gamboge, 
and elaterium are sometimes required where great promptitude and 
energy of action are wanted. In more chronic cases, saline purgatives 
and diuretics are commonly more useful than others, as they seem more 
surely to act as eiiminants where the blood is diseased: but they may 
be advantageously combined with other remedies, such as the prepara- 
tions of dandelion, broom, foxglove, &c. To promote diaphoresis, ex- 
ternal warmth, applied by the vapour bath or hot-bath, is more effectual 
than internal medicines ; but sudorifics, according to my experience, 
are much inferior in utility, as eiiminants, to purgatives and diuretics. 

249. As the effects of ursemia are various in different cases, and even 
in different parts and functions, the means to counteract them must be 
varied so far as they have any efficiency. It is uncertain that we have 
any means of counteracting the narcotic influence of uraemia ; but if 
this depends, according to the notion of Frerichs, on a fermentative 
conversion into carbonate of ammonia, some good might be expected 
from antiseptics and perhaps from the mineral acids. In a conversa- 
tion with Dr. Simpson on this subject, he suggested that part of the 
beneficial influence of chloroform in cases of infantile and puerperal 
convulsions (which are generally connected with ursemia) might be due 
to the chlorine preventing the injurious development of carbonate of 
ammonia in the blood. In more chronic cases of ursemia, I think I 
have seen good results from the free use of chlorate of potass and nitric 
acid, whilst the depression of the muscular power (including the respi- 
ration,) is combated by diffusible stimulants. But the local action of 
the urinary constituents in the blood is irritant; hence arise irritation 
12 



ITS 



ELEMENTARY CHANGES IN THE BLOOD. 



and inflammation of serous and mucous membranes, requiring local 
antiphlogistic remedies, the most efficient of which are blisters. The 
tendency of excrementitious matter to impoverish the blood and to pro- 
mote degeneration of tissues is to be opposed by nourishing diet and 
by tonics, especially those containing iron ; but these are rarely borne 
well, unless in very small doses, and they may be advantageously com- 
bined with iodine, bromine, and salines, as in certain mineral waters, 
which act as eliminants as well as tonics. 

250. The indications of treatment in cholsemia are similar to those 
in uraemia, with this difference, that cholagogue purgatives take the 
precedence of other eliminant remedies. The most potent of these are 
the preparations of mercury; but their weakening operation forms an 
objection to their being used too largely or too long. They may be 
combined and followed by saline aperients and diuretics, especially the 
sulphates of soda, potass, and magnesia, the hydrochlorate and phos- 
phate of ammonia, together with suitable additions of senna, aloes, 
and taraxacum, all of which have a distinct influence on the biliary 
secretion. The nitro-muriatic acid has been reputed to promote the 
biliary secretion, especially when used in a bath or as a lotion over a 
large surface of the body. Nux vomica, in the form of extract, and 
its active principle, strychnia, have also been supposed to exercise 
some influence on the secretion of the liver, whilst they certainly pos- 
sess valuable properties as a tonic to the alimentary canal. 1 

What are called bilious attacks are usually connected rather with an 
excessive than a defective secretion of bile; but probably the chief 
symptoms depend on its imperfect elimination from the liver and its 
ducts, as well as its presence, sometimes in a decomposed state, in the 
stomach and intestines. An emetic and diluents will give the speediest 
relief where vomiting is unavoidable, but it should be followed in due 
time by a mercurial purgative ; and where the sickness is less urgent, 
the latter, with effervescing salines, is generally sufficient. For the 
prevention of these attacks, it is important to avoid all fat and highly- 
sweetened articles of diet ; to be very moderate in the use of fermented 
liquors; to use regular exercise, especially on horseback; and carefully 
to attend to the action of the bowels. 

251. The perspiratory secretion contains lactic acid and lactates of 
soda and ammonia, which probably proceed from the transformation or 
decay of the textures, particularly the muscular, which the researches 
of Liebig have shown to contain a large preponderance of this acid 
(Chemistry of Food, &c, 1847.) Hence these products abound during 
great muscular exertion ; and when perspiration is checked by external 
cold (§ 77,) they are accumulated in the blood, thus often causing rheu- 

1 In cases of prolonged jaundice, after mercury has been used as long as is prudent, 
and the feces are still without bile -whilst the urine is deeply tinged and loaded with 
lithates, the most generally useful combination of remedies that I have tried has been 
that of an effervescing draught comprising the three alkaline carbonates, -with strychnia 
in doses of one-fortieth to one-twentieth of a grain, dissolved in the citric acid used for 
the saline, -whilst the surface of the body is sponged twice daily with a nitro-muriatic 
acid lotion. The extract of nux vomica, in doses of one-sixth to one-third of . a grain, 
twice or thrice daily, is a useful addition to a pill of rhubarb, aloes, or taraxacum, in 
cases of torpidity of the liver and bowels, when it is desirable to avoid the frequent use 
of mercury. 



BY SECKETIOX — rERSPIRATIOX — DEFECTIVE. 



179 



matism, urinary disorders, or cutaneous diseases. The very serious 
effects that sometimes result when cold is suddenly applied to the per- 
spiring body may be partly referred to the same cause, as well as to 
the disorder produced in the circulation. 1 Rheumatism is especially 
liable to occur as an effect of cold and wet, when the body is fatigued 
by much muscular exertion (§ 80 ;) and I have sometimes observed that 
the rheumatism chiefly affects the limbs which have been most exercised. 
"When the skin fails to excrete, increased work is thrown on the kidneys, 
and hence may result various diseases of these organs: if these organs 
fail in the performance of their task, the lactic acid accumulates in the 
blood, and, probably acting as a ferment (§ 56,) causes the formation 
of more and of kindred products: these, in inflammatory subjects, ex- 
cite rheumatic fever; that is, fever, with inflammation of more or fewer 
of the joints, and often of the membranes of the heart. In cachectic 
persons the same acid matters cause miliary fever, erysipelas, or pem- 
phigus ; and in more torpid frames, various local rheumatic or gouty 
affections. Ail these cases are frequently remarkable for the acid cha- 
racter of the cutaneous and renal excretions, 2 and in a few instances the 
blood has been said to possess acid qualities, or to be deficient in its 
usual alkaline reaction. (Dr. Day's Vogel, p. 80.) I have never detected 
any approach to an acid reaction in the serum of the blood in any dis- 
eases, but repeatedly I have found the effusions in serous membranes 
decidedly acicl. In one case of peritonitis, in which the peritoneal 
fluid caused smarting of the hands of the operator, it was found to 
redden litmus paper most strongly. Dr. Garrod, in rheumatic cases, 
always found the blood alkaline. 3 He could not discover any lithic 
acid in the blood of patients with rheumatism, whilst it was always 
present in that of the subjects of gout. In low forms of rheumatism, 
especially the neuralgic, the materies morbi is probably oxalic acid, as 
was originally suggested by Dr. Prout ; for I have in numerous in- 
stances found an abundance of the octohedral crystals of oxalate of lime 
in the urine, especially when the patients began to convalesce. The 
only instance in which oxalic acid has ever been detected in the blood 
was that of a patient suffering from chronic gout, who was for some 
time under my care at University College Hospital. In this case Dr. 
Garrod detected a very appreciable amount of crystals of oxalate of 
lime in the blood. The man died dropsical with albuminous urine ; the 
uriniferous tubes were found obstructed with lithate of soda. (Med.- 
Chir. Trans., 1850.) 

252. The treatment in rheumatism, and other diseases arising from 
defective excretion, therefore, should not be merely antiphlogistic, but 
also of a kind calculated to eliminate the morbid matter from the blood. 

1 Dr. R. Willis has suggested that checked perspiration may prove hurtful by rendering 
the skin dry, and therefore unfavourable for vital changes supposed to take place in the 
cutaneous capillaries. But if this were the only or chief cause of mischief, it might be 
always removed by the warm bath, or any other means of moistening the surface ; so 
also pernicious effects should always result from a dry state of the skin. In neither case 
is this consistent with facts. 

2 In patients with acute rheumatism, I have frequently found the perspiration of the 
affected joints more strongly acid than on other parts. The vesicles of miliary eruption 
contain a fluid which also strongly reddens litmus paper. 

3 Med. Chir. Trans., 1854. 



180 



ELEMENTARY CHANGES IN THE BLOOD. 



In slight cases, topical heat, stimulant frictions, and sudorifics may 
suffice for the cure ; but in most instances, the kidneys and liver should 
be excited to assist in the process of elimination ; and various combina- 
tions of colchicum and alkaline carbonates and other salines, with mer- 
cury, opium, and iodide of potassium, generally effect this purpose very 
satisfactorily, and speedily and permanently remove the disease. 
Where the disease is more decidedly asthenic, and the urine exhibits 
a deposition of oxalate of lime with, or instead of, lithates, or acid 
phosphates, great advantage may be often derived from the employ- 
ment of measures calculated to raise the tone and vital energies of the 
circulating and secreting organs, such as the administration of bark, 
quinine, arsenic, and iron ; and these remedies are the more eligible in 
cases of neuralgic rheumatism, because the attacks are then periodic, 
with intervals of depression that are highly favourable to the influence 
of the medicines. 

Within the last few years two new remedies for rheumatism have 
been much extolled, as effecting a cure more surely and rapidly than 
any mode of treatment previously in use. One is nitrate of potass in 
large closes (from Sss to giij per diem) much diluted with barley-water, 
ptisan, or other diluent. This treatment was strongly recommended 
by several English physicians of the last century, and has recently 
been introduced in France by M. Martin Solon, and here by Dr. Ba- 
sham. The other is lemon-juice, also given in large quantities, as first 
advised by Dr. Owen Rees. There is good testimony in favour of each 
of these remedies, and the trials which I have made of them have con- 
vinced me of their utility; but for certainty and speed in curing rheu- 
matism, they do not appear to me to equal the combination of colchi- 
cum with alkalies, which I have been in the constant habit of using 
during the last twenty years. Both nitre and lemon-juice have more 
action on the kidneys than on any other secretion, and this is the ef- 
fectual mode in which colchicum with alkalies operates ; but it is not 
improbable that the former remedies may have a more direct alterative 
action on the composition of the blood, promoting the destruction of 
the acid morbific matter by combustion or some process of decomposi- 
tion. The acid of lemon-juice is itself certainly decomposed in the 
system ; and it may in its own destruction involve that of the kindred 
lactic or other acid which causes the rheumatism. In this way the 
alkaline lactates are certainly decomposed in the healthy body, the 
lactic acid being converted into carbonic acid and water in the course 
of the circulation. 1 

Neither the lemon-juice nor the nitre treatment has so depressing 
an effect as that with colchicum, and therefore they may be more eligi- 
ble for cases unattended with much inflammatory excitement ; but, it 
may be added, that they are inferior to colchicum in the severer forms 
of the disease, where many joints are affected, and especially those 

1 Dr. Bence Jones has found that the large exhibition of lemon-juice causes the appear- 
ance of lithic acid crystals in the urine; and he justly remarks that this might lead to 
the formation of red sand or calculus (Med. Times and Gazette, Oct., 1854.) This re- 
sult may be prevented by adding a little carbonated alkali to the lemon-juice, an expe- 
dient which I have generally adopted. 



TREATMENT OF RHEUMATISM. 



181 



complicated with inflammation of the membranes of the heart ; in which 
case, also blood-letting, mercurials, and other antiphlogistic remedies 
are required in addition. My own experience would lead me to assign 
to colchicum with carbonated alkalies the highest place in the list of 
remedies for rheumatism, this being the one most efficacious in sub- 
duing the specific or rheumatic element of the disease ; but it is in- 
sufficient where inflammatory excitement runs very high, or involves 
the heart in inflammations which are not merely rheumatic in nature: 
under these circumstances, blood-letting, local and general, calomel 
and opium, and at a later period, blisters, are required in addition to 
the colchicum and alkali. Opium or morphia also affords most valuable 
aid in the treatment in cases of extreme pain or nervous excitement; 
and also where the bowels are irritable and are disposed to diarrhoea 
under the influence of the colchicum. The proper curative action of 
the latter medicine is through the kidneys ; and its beneficial operation 
is generally accompanied by an increase in the solid constituents of 
the urine, as indicated by its quantity and specific gravity. The diar- 
rhoea produced by colchicum and other purgatives often reduces rheu- 
matic swellings for a time ; but the improvement is not lasting, and 
there is usually a relapse of the disease so soon as the purging ceases. 

The eliminating process which colchicum establishes through the 
kidneys should be kept up for some time after pain and other local 
symptoms have been relieved ; but this may usually be effected by re- 
duced doses, and its weakening operation may sometimes be counter- 
acted by combinations with bitters or mild tonics. In cases where the 
stomach and bowels do not tolerate the colchicum, a substitute may be 
found in iodide of potassium, but it is by no means of equal efficacy. 

Both the disease itself, and the chief remedies used to subdue acute 
rheumatism, cause an expenditure of the blood and tissue material, and 
therefore a tonic and nutrient treatment is required to re-establish the 
health; and for this purpose, quinine, iron, the mineral acids, and cod 
liver oil, deserve especial mention as the most suitable aids to nourish- 
ing diet. 1 

It is well to bear in mind that independently of the action of medi- 
cines, Nature has her own methods of purifying the blood from the 

1 The treatment for acute and sub-acute rheumatism generally adopted during my 
charge at the hospital of University College was as follows: — after one mercurial purge, 
colchicum wine was given to all, in doses varying from twenty to sixty minims with the 
same number of grains of carbonate of soda or potash in peppermint water, every four, 
six, or eight hours, according to the severity of the symptoms. In case of disposition to 
diarrhoea, a few drops of laudanum were added. In very acute cases with high fever, 
and many joints implicated, one venesection to twelve or sixteen ounces was sometimes 
practised; and in case of complication with cardiac inflammation, blood was drawn from 
the region of the heart by cupping or leeches, generally followed by blisters. Under the 
same circumstances, calomel and opium or morphia, with ipecacuanha, was generally 
given once or twice daily until the severe symptoms were relieved. 

The general result of this treatment was that on an average of 300 cases, convalescence 
(that is, freedom from fixed pain, tenderness, and swelling) was established in five days: 
but to secure the patient against relapse, the remedies were continued for from one to 
three weeks after; during the latter half of which period the colchicum was combined 
with or replaced by a tonic, and the patients allowed full diet. That the colchicum was 
the most efficient anti-rheumatic remedy employed in this treatment was proved by the 
much more tedious progress of a few cases in which, on accomrt of irritability of stomach 
or bowels, the colchicum was omitted, and the alkalies and mercurials alone continued. 



182 



CHANGES IN THE BLOOD BY TRANSFORMATION. 



materials of rheumatic and kindred diseases; and these methods are 
the more adequate and efficient in proportion to the vigour of the con- 
stitutional powers and the moderate amount of the disease. Thus not 
only by throwing off the acid matter by the kidneys, bowels, and skin, 
but also by its decomposition by the action of the oxygen absorbed in 
respiration, may the blood rid itself of the morbid material ; and it is 
by promoting all these processes that active or athletic exercises gra- 
dually increased, combined with baths or other water cure, have been 
sometimes found a very efficient remedy for chronic rheumatic affec- 
tions. 1 



SECTION XV. 

CHANGES OF THE BLOOD FROM THE TRANSFORMATION OF CHYLE AND 
OF THE TEXTURES OF THE BODY. 

253. The changes of the blood resulting from the transformation of 
chyle and of the textures, involving the processes of nutrition, repara- 
tion and decay, have been too little examined to supply the pathologist 
with a complete view of the subject. It seems quite warrantable, how- 
ever, to connect with these changes some remarkable states of disease, 
on the pathology of which chemistry has thrown much light, gout, for 
instance, and other lithic acid diseases (§ 176,) diabetes, both saccharine 
and ureal, and obesity. 

254. Gout, and the commonest kinds of urinary gravel, are now ge- 
nerally considered to depend on the production in the system of an 
excess of lithic acid. 2 This acid, being a highly azotizecl compound, 
is abundantly generated in those who take a large proportion of ani- 
mal food, and in whom the digestive and assimilative processes are im- 
paired ; the more these processes are weakened, and the less digestible 
and assimilable the food supplied, the more surely will be found this 
acid, with ammonia, the product of degenerating decomposition. Hence 
the disease is engendered not only as a consequence of general full 
living and sedentary habits, but especially from the use of highly sea- 
soned and over-cooked meats, cheese, pastry, and strong acid wines: 
the avoidance of such articles is a more effectual safeguard against 

1 It appears from the experiments of Dr. S. Lelimann and others (Brit, and For. Med. 
Chir. Rev., July, 1855,) that the cold sitz-bath distinctly increases the quantity of urea 
in the urine, probably by augmenting the activity of ihe respiration, which is rendered 
more frequent, although the pulse is slower. 

2 This view, although generally admitted on inferential evidence, was for the first time 
proved in the case of a gouty patient of mine at the University College Hospital, in whose 
blood Dr. Garrod readily detected the presence of lithic acid. The case was one of chronic 
gout, and strikingly illustrated the pathology of the disease by presenting a total absence 
of lithic acid in the urine, until colchicum had been exhibited for some time, when its 
characteristic crystals appeared under the microscope. Dr. Garrod has since succeeded 
in detecting lithic acid in the blood of a large number of persons affected with gout in 
different forms. It is remarkable that before and during a fit of gout, the lithic acid 
disappears from the urine; and Dr. Garrod could not detect it in the blood taken from a 
joint affected with gouty inflammation. It would seem as if the inflammatory process 
in some way decomposed the lithic acid. 



LITHIC ACID — GRAVEL — GOUT. 



183 



gout, than more general abstinence, which in many cases would he 
absolutely hurtful. Lithic acid, like urea, is one of the lower forms 
into which the higher animal principles, fibrin, albumen, and gelatin, 
tend to pass in their progress towards resolution. Hence it is pro- 
duced in excess where there is more azotized matter than is wanted 
for the reparation of the textures, or than the vital assimilating powers 
can appropriate for such a purpose. It results also from the decay 
of the textures after much exertion, and especially during febrile or 
inflammatory irritation, when copious deposits of the lithates appear 
in the urine. 

The morbid effects of an excess of lithic acid vary considerably, 
according to the amount of the excess and to other circumstances. 
The kidneys are the proper emunctories by which it is eliminated from 
the blood, and these sometimes suffer from the irritation which it causes ; 
hence nephralgia and nephritis 1 may occur; or the water and the al- 
kali secreted with it in the urine may be insufficient to hold it in solu- 
tion, and it may be deposited in the form of crystallized sand or gravel, 
or calculus, in the kidneys or bladder; various irritations and obstruc- 
tions in the urinary apparatus are thus induced. 

But sometimes the kidneys may fail in their power of elimination 
(§ 170;) in fact, before a fit of gout, the lithic acid does disappear 
from the urine; it then, with its compounds, accumulates in the blood, 
and may cause various forms of irritation and functional derangement 
(irregular gout, which is extremely common, and of infinitely varied 
kind and seat:) until at length some circumstance may fix the mischief 
in a limb, when a fit of regular gout is the result. In this fit, if per- 
fect, inflammation is excited, and more or less of febrile disturbance, 
which ends with a copious deposit in the urine, affecting the removal 
of the morbid matter (§ 165.) The more acute and fixed the inflam- 
mation, and the smarter the fever, the more abundant is the deposit 
after it, and the more free is the patient from subsequent disease. On 
the other hand, when the inflammation is low, changing its place, and 
with little fever, it generally tarries long, and the system is not re- 
lieved. It is when gout thus lasts long, or frequently recurs, that its 
material so accumulates in the joints as to be deposited in the form of 
a plastery or calculous matter, consisting of lithate of soda (chalk 
stones of gout. 2 ) This chronic form of the disorder is connected with 
a more or less permanent derangement of the digestive or assimilative 
functions, and this renders the treatment more difficult, or less suc- 
cessful, than is that of the more acute forms. In such chronic cases, 
lithic acid seems to be engendered in great abundance, and although 

1 I have in several instances found in the cortical and tubular structure of the kidney, 
clustered crystals of lithic acid, which, under the microscope, exhibited such sharp angles 
and dagger-shaped projections as would afford an easy explanation of the pain, inflam- 
mation, and hemorrhage often attendant on an attack of renal gravel, even when none 
is obvious in the urine. 

2 A case of chronic gout that was under my care in June, 1847, afforded me an oppor- 
tunity of verifying this observation : the matter obtained by puncturing the white tumours 
of the patient's lingers was of a consistence of thick cream, and consisted of very fine 
acicular crystals of lithate of soda, with a trace of lime. Dr. Garrod has found little 
deposits of this kind frequently in the lobe of the ear, and more rarely in the lower 
eyelid. Their most usual seat is in the small joints of the hands and feet. 



184 



CHANGES IN TUB BLOOD BY TRANSFORMATION. 



it is thrown off in large quantities in the urine for an indefinite period, 
yet it never leaves the body free. Such cases are commonly either 
hereditary, or they have been rendered inveterate by intemperate ha- 
bits, or neglect of proper treatment. 

255. In saccharine diabetes, the morbid matter is of a nature that 
is quite contrasted with that of gout and gravel, being grape sugar, a 
wholly unazotized principle ; yet this is also probably produced by de- 
rangement in the processes of digestion and assimilation — the condi- 
tion of the urine being only a consequence of such disorder. The ana- 
lyses of Ambrosiani, Maitlancl, and others, have proved the abundant 
existence of sugar in the blood of diabetic patients, the specific gravity 
of whose serum occasionally rises to 1060 from its presence: Macgre- 
gor has also established the fact of its unusual production during the 
process of digestion. The facility with which starch and gum can be 
converted into sugar in the laboratory, especially under the action of 
acids, throws light on the possible origin of sugar in diabetes ; and the 
actual presence of a very large amount of acid in the stomach in dia- 
betic patients tends to support this mode of explanation. The appear- 
ance of sugar in the urine can scarcely be considered otherwise than 
as a result of its presence in the blood. But sugar is probably formed 
not only from isomeric principles in the food, such as starch, and. gum, 
but in confirmed cases of diabetes may be also derived from a decay 
of the textures, especially the gelatinous, through a modification of the 
process by which urea is naturally evolved ; for it has been found prac- 
ticable to convert gelatin partially into glucocol, which has saccharine 
properties, and probably consists of sugar and urea. Further, it now 
appears, from the researches of Bernard, that the liver has the power 
of forming sugar out of azotized matter ; and that sugar thus formed 
is continually passing through the portal and hepatic veins into the 
vena cava to the right side of the heart ; but it usually disappears in 
the passage of the blood through the lungs. But in case of the re- 
spiratory functions being impaired, as from injury to the floor of the 
fourth ventricle or to the medulla oblongata, the sugar then is not con- 
sumed in the lungs, but passes into the general circulation and appears 
in the urine. It is possible then that the sugar of diabetes may arise 
either from an excess formed by the digestive organs and liver, or by 
an interruption to the process by which the sugar so formed is usually 
consumed in the lungs. Even in healthy subjects, an excessive amount 
of sugar in the food may sometimes cause its presence in the blood 
and in the urine shortly after a meal ; and in aged persons, and in 
those whose respiration is habitually impaired, as with pulmonary em- 
physema, the presence of sugar in the urine is by no means uncommon. 
The trophy and cachexia accompanying diabetes probably result from 
the draining away of the nourishment of the body with the excess of 
sugar, rather than the conversion of all this nourishment into sugar. 
It is now well ascertained that the ordinary animal constituents of the 
urine are not only present, but are often increased considerably be- 
yond their natural amount. 

256. There is a parallel between the indications of treatment in 
gout and in diabetes, although in the fulfilment of these indications 



SUGAH — DIABETES CONTRASTED WITH GOUT. 



185 



the means to be employed are most opposite. In both cases, we must 
withhold those articles of diet from which the morbific matter can be 
most readily generated. Thus it is important to withhold animal food 
and stimulating condiments and beverages in cases of gout, and to use 
these very articles, excluding all saccharine or amylaceous substances, 
in cases of diabetes. In both disorders it is advisable that those pro- 
cesses of digestion and assimilation, from a perversion of which the 
morbid matter is probably generated, should be invigorated. But, un- 
fortunately we know too little of the processes, and of the circumstances 
which influence them, to be able to fulfil the indication with any cer- 
tainty. A gouty constitution, in the absence of the febrile paroxysms, 
is often much improved by the use of bitters and other mild tonics; 
and in diabetes, amendment occasionally takes place during the exhi- 
bition of opium and some of the stronger astringents and tonics, such 
as preparations of iron and copper. As in both gout and diabetes the 
mal-assimilation seems to be connected with an unusual development 
of acidity in the system, alkalies have been found to be alike useful; 
for reasons, however, presently to be mentioned, soda and potass are 
more suited to gout, whilst ammonia and magnesia, or the alkaline 
phosphate of soda, succeed best in diabetes. To ensure their full ef- 
fect, alkalies must be given largely in the form of carbonates. 

In the effect which each exerts on the economy, there is a great dif- 
ference between the morbid matter of gout and that of diabetes. The 
sugar of the latter has no tendency to accumulate in the system and 
produce local derangements ; but, acting as a powerful diuretic, it 
passes rapidly away, carrying with it a great quantity of water and of 
the other constituents of ordinary urine (§ 165 ;) the thirst, dry skin, 
and emaciation of diabetes, seem to be chiefly due to this cause. The 
common complication of diabetes with pulmonary consumption shows 
also that the plastic process of assimilation is therein degraded (§ 211.) 
Diabetes often terminates in death by coma, from failure of the power 
of the kidneys to secrete urine (§ 249,) anasarca usually preceding the 
fatal event. 1 

1 Diabetes is one of those diseases which we may fairly hope to cure when our know- 
ledge of animal chemistry shall be more advanced. The fact that febrile and inflammatory 
diseases suspend it for a time, that is, cause the sugar to disappear from the urine, is a 
proof that the morbid production of sugar is not necessarily permanent, and we may there- 
fore anticipate that it may be prevented by artificial means. Experience has not, however, 
as yet discovered any agent capable of eifecting this in the greater number of cases. Opium, 
alkalies, permanganate of potass, and rennet, have severally been said to be successful in 
a few instances, but they have proved of no avail in general experience. Carbonate of 
ammonia (gr. x. ter die) has seemed to me the most useful medicine for counteracting the 
prevailing acidity, which it does without increasing diuresis or general depression. Cod- 
liver oil is of real service in sustaining the nourishment of the body and removing the 
craving appetite which is commonly present. 

The diet is of primary importance in the treatment of diabetes, as the strict exclusion 
of all saccharine and amylaceous articles constitutes the only sure means of controlling 
the disease. This must be done most rigidly in all decided cases; otherwise little ad- 
vantage will result from restriction. Dr. Prout permitted patients to eat brown bread 
and to drink porter; but in my experience a very small quantity of either of these arti- 
cles has wonderfully increased the saccharine quality of the urine: neither have I found 
gluten bread answer; it is difficult to make well, and it is not relished by patients. The 
best substitute for bread is a biscuit made of fine bran with egg and a little lard. The 
bran must be well washed to remove the flour from it; then dried, and ground fine in a 



186 



CHANGES IN THE BLOOD BY TRANSFORMATION. 



The litliic acid of gout and gravel, unlike the sugar of diabetes, 
has a tendency to accumulate in the body, and to cause the local and 
general irritations already mentioned (§ 254.) Hence it becomes of 
great importance to counteract its irritating properties, and to promote 
its elimination from the system. The medicines which are most 
efficacious in doing this are alkalies, or their carbonates, or their 
vegetable salts, combined with colchicum, or iodide of potassium, saline 
mineral waters, and alterative aperients. These all increase the action 
of the kidneys and intestinal canal, and drain off the offending matter 
from the system ; but the operation of colchicum is far more certain 
than that of the others ; and its permanent efficacy depends especially 
on its continued action on the kidneys more than on any other ex- 
creting organ. The impropriety of using active antiphlogistic treatment 
in gout has long been acknowledged; and it is a general opinion that 
a regular fit of the disease tends to relieve the system from the mor- 
bific matter, and therefore ought not to be checked or too rapidly 
cured. Two facts, first ascertained by Dr. Garrod, and confirmed by 
others, are worthy of note in connexion with this subject. One is 
the disappearance of lithic acid from the urine just before and during 
an attack of gout, and its reappearance on its decline ; the other fact 
is the presence of lithic acid in the blood of gouty subjects, and its 
absence in the blood of the inflamed part. It appears probable, 
therefore, that the gouty inflammation, when acute and sthenic, tends 
to get rid of the lithic acid both by its decomposition in the vessels of 
the inflamed part, and by its elimination through the critical discharges 
which it promotes at its decline. Instead, therefore, of attempting to 
subdue gouty inflammation by leeches, cold applications, and reducing 
measures, it is expedient to promote it by warm coverings of French 
wadding and oil silk, whilst the pain is allayed by occasional applica- 
tions of a little spirit, chloroform, or opium, and the critical discharges 
are encouraged by moderate doses of colchicum with alkalies. 1 

steel mill (made for the purpose by Mr. White, Holborn;) and then mixed with the other 
ingredients and baked into a kind of cake, which is by no means unpalatable, and is 
very much prized by patients who are deprived of bread. Watercress, greens, and cab- 
bage may also be allowed with meat; and a little cream instead of milk with tea or coffee. 
Sound claret, or weak pale brandy-and- water may be used as a stimulating beverage. 

Although it is doubtful how far a cure can be effected by strict exclusion of saccharine 
and starchy food, yet it is quite certain that the disease is suspended by it, and patients 
regain flesh and strength, and may enjoy life for many years. I know several persons 
who were found to be diabetic from five to fifteen years ago, and who are now in the en- 
joyment of very tolerable health, although the urine still contains sugar. 

It is very difficult to estimate the efficacy of medicines supposed to have a direct influ- 
ence in restraining the production of sugar in the system, because the examples in their 
favour are so few. Instances have occurred within my own knowledge in which the 
urine lost all trace of sugar when the patients were taking severally, ammoniuret of copper, 
hydrosulphate of ammonia, tincture of sesquichloride of iron, and liquor arsenicalis. 
Further experience alone can determine whether in any case these medicines were really 
instrumental in producing the change. The permanganate of potass (chameleon mine- 
ral) was recommended as a remedy for diabetes on account of its remarkable oxidizing 
property by which it rapidly decomposes sugar and other hydrocarbonaceous elements. 

1 The treatment of an attack of simple gout is usually an easy affair; in fact, there 
often is such a spontaneous disposition to cure, that it may be wise to interfere as little 
as possible with the process of nature. But it is otherwise with the gouty constitution, 
•which causes a tendency to repeated and prolonged attacks, often of an irregular kind, 
involving the disorder of various functions and derangement of the general health, without 



INCREASED FORMATION OF UREA — 



REMEDIES. 



187 



257. It is supposed by most chemists, that the urea excreted by the 
kidneys is chiefly derived from the transformation or decay of the 
azotized textures of the body (§ 254,) most of their carbonaceous 
matter being abstracted by the affinity of the oxygen in the blood, and 
thrown off from the lungs in the form of carbonic acid gas (§ 232.) 
According to Liebig, whatever excites the activity of the function of 
respiration, which supplies the consuming oxygen, increases the pro- 
duction of urea; active bodily exercise acts in this way. Under 
some circumstances, however, the formation and excretion of urea is 
much augmented, without any obvious excitement of the respiratory 
function. This is the case in the diabetes ureosus described by Dr. 
Prout, and which he considers a forerunner of saccharine diabetes. 
Such free production of the matter which seems to be properly a kind 
of debris of the body, indicates organic debility, or exhaustion of the 
vital powers, and has been observed to occur in young persons who 
have grown rapidly, and in those weakened by great mental exertion 
and want of sleep, or by venereal excesses. An excessive excretion 
of urea (or of carbonate of ammonia, which is of kindred composition,) 
sometimes takes place in typhoid fevers, and is attended with great 
loss of flesh and strength. A great and sudden increase of urea in 
the urine was ascertained to have taken place, in some patients with 
acute rheumatism, and in others with delirium tremens, in University 
College Hospital, at the decline of the fever and other acute symptoms. 
This perhaps ought to be viewed as arising from the removal of the 
urea which had accumulated, rather than from an increased formation 
of \t ; and this fact may be connected with another ascertained by 
Professor Chelius and Dr. Lewins, namely, that colchicum causes an 
augmented discharge of urea and the other organic principles of the 
urine (§ 252, 173.) The operation of diuretics, especially those con- 
any disposition to a spontaneous termination. Now this gouty constitution is also depen- 
dent on the production of an excess of lithic acid in the system; and although generally 
more amenable to the action of eliminant remedies, especially colchicum with alkalies, 
than to any other treatment, yet the -weakness of stomach and other organs, occasionally 
predominant, may much interfere with the use of these remedies and may call for others 
of a different class. Thus where the circulation is very weak, bitters, tonics, and even 
stimulants may be necessary to enable the excretory organs to throw off the morbid matter; 
and any weakening influence which the eliminatory medicines may have, may be more 
or less counteracted by these means. But there is a seat which the gouty disorder some- 
times occupies, which entirely interrupts the usual course of treatment, and may render 
the case unusually grave. This is when it attacks the stomach, causing more or less 
pain, nausea, and obstinate vomiting. Here colchicum and iodide of potassium are quite 
out of the question; and except small effervescing draughts with an excess of alkali and 
a little hydrocyanic acid, and a few grains of simple calomel, medicines of any kind are 
rarely tolerated. Small bits of ice slowly swallowed, should take the place of drink ; 
and the only nourishment likely to be retained is in spoonfuls of milk and soda-water, 
chicken tea, or thin arrowroot flavoured with brandy. In some instances the vomiting 
has been checked by sinapism to the epigastrium, or by minute doses of strychnia (from 
one-fortieth to one-twentieth of a grain;) in others opium or strong stimulants have been 
successful. 

According to my experience, gout in the stomach is the most formidable variety of the 
disease, and therefore it is the more important to be guarded against. The occurrence 
of any nausea, or pain in the stomach, should be taken as a warning against the con- 
tinuance of colchicum or any other medicine of a sickening tendency ; and in the in- 
tervals between attacks the tone of the stomach should be strengthened by bitters, with 
a due attention to the diet and regimen. 



188 



CHANGES IN THE BLOOD BY TRANSFORMATION. 



taining alkaline and saline matter, is also eliminative, promoting the 
removal from the blood of the products of decay; but it is very pro- 
bable that both these and saline mineral waters, and even plain water 
when taken in excess, tend to increase the waste of the blood and of 
the tissues nourished by it (§ 231.) 

In cases of excessive formation of urea, all circumstances which 
depress or exhaust the organic life should be avoided, as for instance 
great excitement of body or mind ; waste should be compensated for 
by a generous diet, and the nutritive function should be sustained by 
tonics. Opium and other narcotics are found to be useful in reducing 
the quantity of urine in the diabetes ureosus; and they probably 
operate by calming exhausting nervous excitement, and by procuring 
sleep. The researches of Dr. Bocker show that alcoholic liquors, tea, 
and coffee, also restrain the waste of the tissues, and thus become the 
means of giving strength to the frame (§ 56 :) in this respect they are 
contrasted with simple water and mere diluents which have a tendency 
to promote waste, as these augment the solid contents of the excretions. 

258. The eduction, or production, of fat from food takes place 
with remarkable activity in some persons ; and wherever it obstructs 
or supersedes the proper formation of fibrin and other protein princi- 
ples more immediately concerned in giving strength to the bodily 
frame, it amounts to disease. The circumstances in the diet which 
tend to this result have been already noticed (§ 59, 60,) and we have 
had occasion to mention that sedentary habits and a lowered condition 
of the respiratory function have sometimes a similar effect (§ 239, 65.) 
But in connexion with our present subject we may remark that there 
are many reasons for supposing that an excessive production of fat 
sometimes occurs as an error in assimilation, and may interfere with 
the sufficient production of other animal principles and with the 
nourishment of the textures of kindred composition, whilst it not only 
accumulates in its proper tissue, but invades other textures, lowering 
their vitality and cohesion, and thus constituting a cause of gradual 
degeneration. Thus Mr. Gulliver has shown that the atheromatous 
patches in the coats of arteries, which appear to be a mark of de- 
clining age, (natural or premature,) are of the nature of fatty degenera- 
tion. The same pathologist has discovered a predominance of fatty 
matter (chiefly olein, margarin, and cholesterin) in the lungs, the 
kidneys, and testicles, in various chronic diseases. (Med. Gazette, 
June,. 1843.) A similar abundance of fat has been frequently observed 
by myself (first in conjunction with Dr. B. Quain, in May, 1845) in 
the kidneys, liver, and other structures of persons whose habits of 
excessive intemperance proved fatal, w T ith the production of general 
cachexia and failure of many functions. This subject will be noticed 
again under the head of perverted nutrition, when the remedies to be 
opposed to the morbid element, fatty transformation, will be considered. 



CHANGES IN THE BLOOD BY FOREIGN MATTERS. 



189 



SECTION XVI. 

TOXJEMIA — CHANGES IN THE BLOOD FROM THE PRESENCE OF 
FOREIGN MATTERS. 

259. The blood is probably the chief seat of the morbid poisons 
•which excite various contagious (§ 93,) epidemic (§ 88,) and endemic 
diseases (§ 81 ;) and where these act most intensely it is much changed 
in its physical characters, being rendered darker, indisposed from 
defect of fibrin to coagulate, with breaking up of many red corpuscles. 
Probably, too, the blood is the hot-bed in which morbid poisons are 
propagated, whether by seeds, ova, cell-germs, or parasites (§ 99 ;) and 
it is through changes in its composition that many of the destructive 
effects of these poisons are produced (§ 186, 196.) We have already 
noticed some of these changes under former heads of our subject. It 
will suffice in this place to mention a few examples in which morbid 
poisons have been traced to the blood. 

Dr. Francis Home communicated measles from one person to another 
by inoculating with the blood of a patient affected with the disease. M. 
Gendrin describes the following experiment: — A man who had been 
skinning a diseased animal was seized with a putrid fever, attended 
with an eruption of sloughing pustules. Some blood taken from this 
man was injected into the cellular texture of the groin of a cat; the 
animal was soon affected with vomiting of bile, dyspnoea, frequent 
small irregular pulse, dry brown tongue, with slight convulsions, and 
died seven hours after the injection. The same pathologist produced 
in animals various severe symptoms, speedily ending in death, by in- 
jecting into their veins blood taken from a person labouring under 
confluent small-pox. MM. Dupuy and Leuret communicated to a 
healthy horse the malignant pustular disease called "charbon," by in- 
jecting into its veins some of the blood of a diseased animal; and M. 
Renault propagated glanders from one horse to another in a similar 
way. Andral quotes from Duhamel an extraordinary case, in which 
blistering, pustules, malignant fever, and death, followed the mere con- 
tact of the diseased blood of an animal with the lips. Other instances 
are on record of sickness, faintness, and serious illness being caused 
by the odour of blood ; and Dr. Copland quotes from Zacutus a mar- 
vellous story of three persons being struck dead by the smell of the 
blood of a patient in the plague. 

The mutual influence exerted between various morbid poisons and 
the blood may be traced in numerous facts in . the clinical history of 
toxemic diseases; and a few examples may serve as illustrations of 
the subject in relation to its practical bearings. 

It has been already stated that the disposition to suffer from zymotic 
diseases (Sect. III., Div. II.) is connected with a weakness of the func- 
tions generally (§ 23,) but it is more particularly favoured by the 



190 



CHANGES IX THE BLOOD BY FOREIGN MATTERS, 



presence in the blood of an easily decomposed azotized matter result- 
ing from the retrograde transformation or decay of tissues (§ 105.) 
Thus after great bodily fatigue ; after severe wounds or other injuries ; 
and after delivery of women, where there is more than usual of an effete 
matter in the blood, there is great susceptibility to zymotic diseases 
and a liability to them in an aggravated form. So also in the deve- 
lopment and progress of these diseases, we have many proofs that their 
essential seat is in the blood, though their action may be exerted on 
various tissues or organs. Thus the earliest symptoms are those of 
general weakness and uneasiness, with disturbance of the circulation 
more constantly than of any other function ; and not unfrequently, 
as before mentioned, with an obviously altered condition of the blood. 
In the worst cases of zymotic disease, where the poison is most viru- 
lent, the change approaches to putrescence; and the excretions first, 
and eventually the whole body, exhale offensive odours, and give evi- 
dence of the prevalence of a decomposing force opposed to the conser- 
vative powers of life; and this corrupting influence may triumph in a 
few days or even in a few hours before any secondary or local changes 
can take place. This has been observed to happen in the plague and 
in the worst forms of putrid or pestilential fevers, in which the blood 
seems to be so rapidly corrupted that it no longer sustains the func- 
tions of life. In like manner the poison of the most venomous serpents 
appears to exert its deadly influence on the blood, which it renders the 
medium of death to the whole body. 

But the more usual operation of zymotic poisons is of a more mixed 
character, comprising much local irritation as well as constitutional 
disturbance and depression. Thus the poisons of the exanthemata 
produce various specific forms of cutaneous inflammation ; and that of 
scarlatina also affects the throat and frequently the uriniferous tubes, 
and measles the air-passages, — with inflammatory or congestive dis- 
orders. The follicular intestinal lesions in typhoid fever, and the more 
intense phlogoses and ulcerations of epidemic dysentery, are farther ex- 
amples of local irritation resulting from the presence of a morbid poi- 
son in the blood. Now although these local inflammations are proofs 
of the activity of the respective poisons, and are, in fact, the foci of 
their multiplication, yet they truly appear to be parts of a process by 
which the poison is brought to a surface from which it may be elimi- 
nated from the system and the blood freed from its contaminating in- 
fluence; for they all involve more or less of a process of effusion and 
discharge, and the more simply and superficially this takes place, 
without spreading deeply and disorganizing the textures, the more 
favourable will be the result. Thus scarlatina, the eruption of which 
is vivid and soon ending in desquamation, the throat-inflammation su- 
perficial and attended with free secretion; — measles with full florid 
eruption, and the catarrhal affection ending early in defluxion and ex- 
pectoration ; — small-pox with distinct pustules circumscribed by a firm 
phlegmonous base, which protects the system whilst the pustule matu- 
rates, and then soon dries into a hard inert scab ; typhoid fever, — in 
which an early moderate diarrhoea indicates the activity of the intes- 
tinal follicles in throwing off the morbid matter; — these are examples 



ZYMOTIC POISONS — OPERATION. 



191 



of the favourable operation of the vis medicatrix naturcc in the removal 
of a noxious influence. On the other hand, in scarlatina, — where the 
eruption is not persistent or is livid, and the throat inflammation is 
deep-seated, -with much swelling, sanious and fetid discharges, and 
sloughy patches; in measles, — with a dusky and imperfect rash, and 
the inflammation of the air passages assuming the form of croup, ex- 
tensive bronchitis, or even of pneumonia; in small pox, — a very co- 
pious eruption of confluent, flattened pustules, with little or no indu- 
ration at their base, but much dark red diffuse swelling of the integu- 
ments and cellular tissue, sometimes with purple ecchymosed spots or 
petechia, and sanguinolent discharges from various mucous membranes ; 
in typhoid fever, — a torpor of the bowels and other excreting organs, 
with tympanitis, dark sordes on the teeth and tongue, petechise on the 
skin, and general oppression of all the functions; — in such forms of 
disease we see evidence of a prevalence of the operation of the poison 
in depressing the vital powers, in injuring the condition of the blood, 
and in depressing the local processes intended for the protection of 
the s} T stem. Various combinations and complications of these two op- 
posing influences, — the poison, and the reaction against it,— -constitute 
the infinite diversity in type and form that toxeemic diseases present. 

There is good reason to suppose that purulent matter, the germs 
(§ 90) of carcinoma, and other forms of malignant disease, are spread 
through the system by the medium of the blood. Pus has been fre- 
quently detected in the blood by the aid of the microscope, first by Mr. 
Gulliver, and by many subsequent observers. The pus globule is to 
be distinguished from the pale or lymph corpuscle by its larger size, 
more marked and often granular cell- wall, by its contained granules 
or nuclei being more distinct, and sometimes loose in its interior, and 
lastly by its exhibiting exosmotic and end osmotic properties much more 
actively. The different effects of pus in the blood will be noticed under 
the head of results of inflammation. The tendency to symmetrical 
arrangement which cutaneous eruptions, nodosities of the joints, para- 
lysis from lead, and some other local affections exhibit, has been ad- 
duced, by Dr. W. Eudd and Mr. Paget, as an instance of effects pro- 
duced through the medium of the blood — the symmetrical distribution 
of this fluid on the opposite halves of the body leading to like results 
in corresponding parts. 

260. It is very evident from the phenomena and results of toxaemic 
diseases, that the blood itself and the organs connected with it possess 
a certain preservative and correcting power, by the operation of which 
efforts are made to counteract or throw off any noxious matters which 
may be present in the circulating fluid. The success of these efforts 
will depend much on the vital vigour of the blood itself and of the or- 
gans of circulation and depuration, as opposed to the quantity and vi- 
rulence of the invading poison. When the latter operates with the 
greatest energy, as in the bite of the most venomous serpents, or 'in 
the most malignant forms of pestilential fever and cholera, the poison 
seems to overwhelm all resistance, and destroys life in a few hours, 
apparently by its direct deadly action on the blood and living tissues. 
The blood after death commonly remains fluid, or imperfectly coagu- 



192 



DISEASES OF THE BLOOD. 



lated, and often it is extravasated in parts, and deeply tinges the tis- 
sues in contact with it. Even where the poison is less rapidly and 
directly destructive, the resisting and eliminating processes, although 
brought into operation, may be insufficient to prevent a fatal result ; 
and where the struggle is more prolonged, its marks are usually seen 
not in the blood only, but also in the mucous surfaces, skin, glands, 
and other organs, which become irritated, congested, inflamed, and 
even disorganized in the ineffectual processes of resistance and elimi- 
nation. In this way arise the specific inflammations of the skin in ex- 
anthematous fevers, of the throat in scarlatina, of the nose and bron- 
chial membrane in measles, of the follicles of the intestines in typhoid 
fever, and the irritative discharges of epidemic cholera, dysentery, and 
yellow fever. In these several instances, the direct operation of the 
poison and that of the reaction against it, appear to be equally destruc- 
tive, and together constitute the features of these respective diseases 
in their ordinary severer forms. On the other hand, the milder varie- 
ties of these maladies show the influence of a moderate operation of 
the morbid poison, disguised in various degrees by the several processes 
of irritation or reaction peculiar to each disease. 

The preceding view of toxemic diseases may be extended to com- 
prise the most useful facts ascertained with regard to their treatment. 
With the most energetic kinds and degrees of poison in the blood, re- 
medies are of little or no avail ; chemical antidotes capable of destroy- 
ing the poison would be equally injurious to the blood which contains 
it; and if aid is to be derived from any agents, it is chiefly to be looked 
for from stimulants and antiseptics, or those which excite the vital 
functions, and those which resist the tendency to decomposition in the 
animal fluids and solids. And if the influence of the poison is not of 
the most rapid and overwhelming kind, such means may so far coun- 
teract it as to give time for the processes of oxidation and elimination, 
which are the natural means by which the system is freed from noxious 
matters. 

In the treatment of cases of toxaemia we have, then, to hold in view 
these indications : — 1. To counteract as far as possible their injurious 
influence, both general and local; 2. To promote their decomposition 
and expulsion from the system; and 3. To regulate the functions and 
sustain the nutrition of the body, during the struggle which may last 
some time between the disease and the bodily powers. A few examples 
may- serve to illustrate the fulfilment of these several indications. 

In the treatment of persons under the influence of sedative poisons, 
such as digitalis, hydrocyanic acid, aconite, &c.^ which act through the 
blood, we endeavour to counteract their depressing influence by diffu- 
sible stimulants, such as ammonia, alcohol, ether, and artificial heat. 
In case of poisoning by narcotics, such as opium, alcohol, and dele- 
terious fungi, we endeavour to excite the torpid sensibility and main- 
tain the respiratory movements by cold affusion, sternutatories, sina- 
pisms, mechanical irritation, electric shocks, &c, and by strong coffee 
and tea, which counteract the soporific tendency. If these means are 
successful in countervailing the operation of the poison for a certain 
length of time, the danger is removed; for the poison in that period is 



ZYMOTIC POISONS — COUNTERACTION AND ELIMINATION. 193 



so far decomposed or eliminated, that the system is relieved from its 
effects. In like manner the poisons of typhous and other adynamic 
fevers have their depressing operation, which is to be counteracted by 
the judicious administration of wine, ammonia, and other stimulants; 
but these morbid poisons are more persistent than vegetable sedatives 
and narcotics, and remaining longer in the blood, require a continued 
use of not only stimulants, but also of eliminant remedies, which aid 
the secretions in expelling them from the system. Further, it has 
been mentioned that these morbid poisons show more or less of a 
septic tendency, sometimes in their direct action on the blood, and 
always in their increasing the putrefactive properties of the excremen- 
titious matter, which by their peculiarly offensive odour give evidence 
of the advance of decay. To limit this process of decomposition, and 
to deprive its products of their injurious properties,, antiseptic reme- 
dies become useful ; and for this purpose, chlorinated liquids, nitro- 
muriatic acid, chlorate of potass, chloric ether, creasote, and powdered 
charcoal, have been employed both externally and internally for various 
toxemic diseases. Bark and quinine may be considered to possess 
some title to the same property, but they appear also to have impor- 
tant relations to the vital property of tonicity (§ 124,) which give them 
an antagonistic power against the poison of fevers in general, but more 
especially of intermittent and remittent fevers. The power of quinine 
in large doses to cut short the course of continued fever is still a mat- 
ter of question ; and although the experience of a few practitioners 
testifies in its favour, there is not that concurrence which would be 
required to establish the efficacy of a great remedy, like that of the 
same medicine in intermittent diseases. But this last example of re- 
medial action, that, namely, of bark, quinine, and arsenic in inter- 
mittent diseases, is also one of antidotal or antagonistic kind, opposed 
to the operation of a poison or noxious principle in the blood; and in 
farther illustration of this position maybe adduced the important fact, 
accredited by several experienced observers, that small doses of qui- 
nine (a grain twice daily) are protective against malarious poisons in 
persons exposed to their influence. 

Another instance of counteractive treatment of blood poison in a 
more limited degree is in the exhibition of opium and other narcotics 
to soothe pain or nervous irritation (§ 149 — 53) caused by the opera- 
tion of the poison. In ataxic, or nervous forms of fever, in delirium 
tremens and other toxemic affections attended with nervous excitement, 
the operation of narcotics is salutary, not counteracting altogether the 
morbid poison, but in controlling one of its most mischievous effects, 
which tends to wear down the vital powers by exhausting excitement. 
It is very probable that part of the salutary operation of wine and 
other stimulants, especially chloroform and chloric ether, may be due 
to their tranquillizing influence on the nervous system, whilst at the 
same time they sustain the power of the muscular. 

But it is by promoting their elimination that nature and remedial 
art more constantly and successfully operate against noxious matters 
in the blood. Orfila found that even energetic mineral poisons, such 
as arsenic, could be given to animals in small repeated doses without 
13 



194 



DISEASES OF THE BLOOD — TOXEMIA. 



any injurious effect so long as a diuretic was exhibited at the same 
time ; and it is well known that the poisonous action of lead, in those 
whose occupations expose them to it, may be prevented by keeping the 
bowels constantly free. Fevers and other toxemic affections are some- 
times carried off by a spontaneous diarrhoea, a diuresis, or a copious 
sweat: and the artificial treatment which most seems to promote a fa- 
vourable termination of these disorders is that which moderately ex- 
cites these secretions. Thus mild doses of mercury, antimony, salines 
comprising all the alkalies combined with citric, acetic, or tartaric acid, 
and increasing the proportion of ammonia and adding stimulants as 
the weakness requires, — are the most generally useful medicines in these 
diseases ; and an indication of their successful operation is the free 
flow of the several secretions, often offensive at first, and giving proof 
of their containing much decaying animal matter, but gradually be- 
coming more natural as the disease yields. On the other hand, in un- 
favourable cases the eliminatory process fails, the discharges being 
either scanty, or so depraved and offensive as to injure the function 
and structure of the excreting organs, and the body loses all chance 
of being freed from the deleterious operation of the morbid poison. 
With these facts may be connected that of the peculiar liability to in- 
fectious diseases (§ 17, 26, 32) shown by persons affected with lesions 
of the kidney which impair its excernent function; and when such are 
attacked, they rarely recover. Similar observations may be made re- 
specting various pharmaceutic poisons which operate through the blood, 
such as opium, arsenic, and mercury, which act with uncommon, and 
therefore with dangerous energy on those whose excreting functions 
are much impaired, either by structural disease, or by extreme weak- 
ness or exhaustion. 

In all toxemic diseases of a severe kind there is a remarkable ex- 
penditure of flesh and strength. The changes which the poison induces 
in the blood tend to spoil it for the purpose of nutrition, the function 
of which is therefore suspended for the time, and emaciation proceeds 
with the accelerated decay of the materials of the blood and textures. 
Hence the importance of affording fresh supplies of nutritious food in 
such forms and as frequently as the digestive organs will allow. Ani- 
mal broths and jellies, and farinaceous liquids are commonly the most 
eligible forms during the continuance of the febrile process ; but they 
may be .often advantageously administered in small quantities every 
hour or every two hours, with wine or brandy, according to the state 
of depression. The utility of alcoholic liquors in checking the waste 
of the body, when judiciously administered, may be better understood 
by a reference to what has before been mentioned with regard to their 
action in this respect (§ 56.) In many fevers the gastro-intestinal 
mucous membrane is so much irritated that even during convalescence 
solid food is not borne for a long time, and the restoration of flesh and 
strength is proportionately slow. In such cases, as well as in others 
in which alimentation is difficult, I have found great benefit from the 
use of the cod liver oil in small doses after each meal, which commonly 
agrees well even in cases in which the irritable state of the alimentary 
canal will bear neither strong animal food nor tonics. 



195 



CHAPTER III. 

SECONDARY OR PROXIMATE ELEMENTS OF DISEASE, CONSISTING OF TWO 
OR MORE PRIMARY ELEMENTS (§ 804.) 



SECTION I. 
ANiEMIA. 

261. The class of proximate elements which have been most gene- 
rally studied as the subjects of general pathology, are those affecting 
the circulation of the blood. They comprise at least three of the 
primary elements which have been considered — the condition of the 
blood and its constituents, the irritability of the organs (§ 110, 120) 
concerned in its distribution, and their tonicity. A previous ac- 
quaintance with these elements will render very intelligible many of 
the phenomena that result from their combination, but it is necessary 
to keep in view also the physical properties of the vessels and their 
contents; for these properties, when altered, become themselves ele- 
ments of disease. Thus a mechanical obstruction or an enlargement 
of a blood vessel contributes to the production of disease as much as 
a change of vital properties. So it is impossible to understand the 
effects produced by the presence of too much or too little blood in 
the vessels, without a due consideration of the mechanism of the cir- 
culation. 

We shall briefly consider the morbid conditions connected with de- 
ficiency and excess of blood in the vessels, under the divisions of gene- 
ral and partial, and as attended with an increase or diminution of 
the irritability and tone of the moving fibre. It is to be understood 
that all the proximate elements of disease now to be considered, may 
occur either as distinct affections or in combination with other maladies. 

262. Anaemia, or as it has been more correctly termed, hypccmia, 
or oligcemia, is the name applied to that condition of the system in 
which the predominant character is a deficiency of blood. But as to- 
gether with this deficiency in quantity, there is very generally a re- 
markable deterioration in quality also, the late Dr. Simon applied to 
the condition the term spanoemia (csnavo?, poor.) 

263. The causes which excite anaemia are, various circumstances 
which injure the blood, or withdraw portions of it from the system 
(§71,) and especially such as drain off the red corpuscles, or inter- 
fere with their formation (§ 66:) of this nature are excessive bleed- 
ings, or hemorrhages; profuse evacuations of fluids which contain in 
themselves much of the organic constituents of the blood — as bile 
and pus, for instance; feeding scantily, or on such substances as con- 



196 



ANiEMIA. 



tain little animal matter or protein; confinement in impure air, dark 
places, or malarious districts 191;) the suffering of certain chronic 
maladies which deeply affect the constitution, such as scorbutic, tu- 
berculous, and cancerous diseases, structural degenerations of the 
kidneys, and diseases of the spleen and liver, attended with great 
enlargement (§ 185, 222, 249:) but the commonest cause of all is 
irregularity of the uterine function, which induces the disorder long 
familiar under the designation of chlorosis. It might seem difficult to 
understand how this last operates, but an explanation has already 
been suggested (§ 191 :) that in many cases the irregularity is a cause, 
and not an effect of anaemia, is plain from the well known fact that 
no signs of anaemia occur until cold, over-exertion, mental excitement, 
or some like circumstance, suddenly checks the flow of the catamenia ; 
it does not return; and then the patient begins to lose colour, and 
gradually to exhibit the anaemic state. In many cases I have known 
this to occur with young females who have previously suffered from 
acute rheumatism, implicating the heart. It appears here that some 
injury is clone to the blood corpuscles and to the powers by which these 
are reproduced: this is manifested not only by the palliclity, but also 
by the yellowish and almost greenish hue, which the complexion com- 
monly assumes, and which obviously depends on a discoloration of 
the textures by the altered blood, as happens in the neighbourhood 
of a bruised part. The nature of these changes has been already 
noticed (§ 185-6, 191.) In some cases of chlorosis, the appetite is 
depraved (§ 131;) there is such a complete disrelish for animal food 
and other nourishing articles, and such a craving for sour thiugs, and 
even for matters destitute of nourishment, like chalk, and cinders, 
that it might almost be supposed that the perverted appetite deter- 
mines the anaemia, by deterring the patient from taking such food as 
is capable of making red blood; and undoubtedly such perverted 
appetites, when indulged, must contribute to this result; but as they 
are not constantly present they cannot be considered the chief cause 
of the anaemia, in those examples where they do occur. 

Anaemia is often symptomatic of various other maladies, particularly 
of chronic and cachectic affections; but it sometimes occurs without 
any other manifest disease, and its symptoms then exemplify in a 
striking manner the way in which the various functions suffer from 
want of a due supply of the vivifying fluid (§ 183, 185.) 

The general symptoms of anaemia are weakness (§ 116;) muscular 
weakness, evinced by the faintness, breathlessness, and fatigue follow- 
ing upon exercise; weakness of the heart, shown by the feeble, loose, 
or thready pulse, rendered very frequent and palpitating by slight 
exertion, or change of position, and often becoming irregular and 
failing afterwards; feebleness of the whole circulation (§ 123.) mani- 
fest in the coldness of the surface of extremities; organic weakness, 
shown by the loss of appetite, indigestion, torpor of the bowels, and 
scanty and disordered secretions (§ 172;) defective nutrition (§ 211,) 
especially of the muscular parts: and imperfect sanguification, for 
the blood that remains in the system is diseased, being poor and 
watery, as well as scanty (§ 185, 222.) 

264. There are also distinctive physical signs of the scantiness of 



SYMPTOMS AND SIGNS. 



107 



blood in the body: the surface is remarkably pallid; even the lips, 
gums, and tongue, show none of their healthy ruddiness. The com- 
plexion modifies the amount and kind of the paleness; dark persons 
often appear yery sallow, or even of a yellowish or greenish tint, 
and those of fair complexion having a ghastly pallor. If blood- 
vessels are seen at all, it is only the larger superficial veins, which 
are pink instead of blue, in consequence of the paucity and transpa- 
rency of the blood in them. In the course of the larger veins, 
(especially the jugulars in the neck,) the thin blood may be heard 
running with great rapidity, for it is readily thrown into sonorous 
vibrations (venous murmurs,) as it courses through the ill-filled vessels ; 
these vibrations are sometimes sensible to the finger placed lightly on 
the vein, as a sort of thrilling movement. The same thinness of the 
blood, connected with an abruptness in the heart's contractions (§ 113,) 
frequently causes a murmur with the first sound of the heart, refer- 
able to the aortic orifice : as, however, this murmur varies much in 
different cases, being scarcely audible in some, whilst it is loud and 
harsh in others, it is obviously dependent in part on some irregularity 
or narrowing at the mouth of the aorta, too trifling to give any 
obstruction or sound when the blood is abundant and of due spissi- 
tude, but readily causing vibrations and sonorous gushes when the 
fluid is thin, and the relations between the size of the heart and 
arteries are somewhat changed. The rapidity of the motion of the 
blood also increases the loudness of the murmur ; under the influence 
of an excited heart the systolic murmur sometimes extends far into 
the arteries, and even again reappears, after it has been lost, where- 
ver the artery presses on other solids, be it ever so slightly, as for 
instance while passing under the clavicles; The venous current, on 
the other hand, is more under the influence of gravitation, and its 
murmur is therefore loudest in the jugulars in the erect or sitting 
posture. 

265. The blood of anasmic subjects is found to be very thin and 
watery when it is drawn from a vein. It readily coagulates, and 
forms a very small contracted clot (§ 207,) generally covered with 
a bufify coat. This appearance, which was formerly erroneously 
ascribed to inflammation, is probably due, as Andral surmised, to a 
predominance of the fibrin over the red corpuscles, for these are 
diminished much more than the fibrin, being in extreme cases re- 
duced to one-fifth of their natural amount (§ 185.) The albumen is 
also generally scantier than usual ; a remarkable exception which 
occurs in the ansemia attendant on paraplegia has been already 
noticed (§ 221.) 

266. Although the symptoms of anasinia are chiefly those of great 
weakness or depression (§ 262,) there are often others of an opposite 
character, indicating irritation or exaltation of function. Some of 
these arise indirectly from the weakness, as, for example, pain in the 
left side and epigastrium, nausea, colic, and diarrhoea (§ 56, 168, &c.,) 
which may be traced to weak digestion leading to the production of 
sundry irritating matters out of the food which has been used for 
nourishment. But other more direct traces of excitement sometimes 
occur, particularly if great loss of blood have happened just before. 



198 



AM MIA. 



Various functions of the nervous system are exalted; sensibility 
becomes very acute (§ 126 ;) there is intolerance of light and sound, 
with the occurrence of flashes in the eyes, noise in the ears, a sense 
of rushing in the head, and various neuralgic pains. The excitomo- 
tory nerves are sometimes involved in the irritation, (§ 140, 150,) 
and spasms or convulsive affections of different kinds may be present; 
or the organic functions may be morbidly excited, and palpitation, 
spasmodic asthma, vomiting, and other sympathetic irritations, occur. 
In a few instances, angemia has been attended with delirium, or mental 
excitement bordering on it. 

267. It thus appears that the functions which are mostly excited 
in the midst of general depression and weakness, are those of the 
nervous centres ; the generally nervous character of persons in a 
state of great weakness (§ 113) is connected with this same fact, so 
that nervousness and weakness are really almost synonymous terms. 
No explanation of this apparent anomaly has been to my knowledge 
proposed; but one seems to suggest itself, in the peculiar distribution 
of the circulation through the nervous centres. When the mass of 
the blood is reduced in quantity, the blood-vessels generally contract 
in proportion, their tonicity adapting their area to the bulk of their 
contents (§ 120.) But the vessels within the skull and spinal canal 
cannot contract with the same facility, in consequence both of their 
not being exposed to atmospheric pressure, and of their position 
mostly within bony canals ; they do not shrink as the blood within 
them becomes reduced in quantity, and therefore they retain more 
than their proper share of the circulating fluid. 1 This dispropor- 
tionate amount of blood in the nervous centres produces different 
effects, according to the degree in which the heart's propulsive power 
(§ 111) affects it. Under the influence of temporary palpitation 
(§ 112,) fever, or other kind of excitement, the brain and spinal cord 
receive an unusual share of the exalted but partial force, through 
their uncontracted vessels which are among those most open to the 
heart's impulses. An erethism of some one or more of the functions 
of these nervous centres (§ 127, 133, 153) is the consequence; and 
pain, spasm, sensorial excitement, intolerance of light and sound, or 
sympathetic irritations of some kind or another, take place. In this 
condition the head may be hot and throbbing, the face flushed, and 
the eyes suffused, whilst the extremities, and the surface generally, 
are comparatively bloodless, and either cold, or very speedily be- 
coming so on exposure. Epistaxis sometimes occurs, but although 
bringing momentary relief, may, if considerable, add to the evil, by 
increasing the angemia. 2 

1 This statement is not invalidated by the experiments of Dr. Burrows, (Med. Gaz., 
April, 1813.) His experiments and expositions very satisfactorily demonstrate the ab- 
surdity of the notions expounded in Dr. Kellie's paper, that the quantity of blood in the 
head is always the same; but it is nevertheless clear that the circulation within the 
head and spinal canal, especially in man, is affected by losses of blood differently from 
the circulation in other parts. 

2 Although the chief effect of excitement of the circulation in anasmia is thus directed, 
to the nervous centres, it is by no means confined to them. Other parts in the imme- 
diate vicinity of the heart become the seat of increased arterial pulsation and distur- 
bance. Thus a painful throbbing is often complained of in the throat, chest, and epi- 
gastrium, even when there is little pulse in distant arteries, and the extremities are 



ENCEPHALIC CONGESTION. 



199 



268. On the other hand, if the heart's action is feeble (§ 116) it 
may be inadequate to propel the blood accumulated in the vessels of 
the brain: this therefore stagnates, and may cause some of the 
symptoms of cerebral congestion. Headache and giddiness, relieved 
by the recumbent posture, drowsiness, impaired mental faculties, 
obscured, vision and hearing, partial paralysis, and, in extreme cases, 
coma or catalepsy (§ 129, 133, 141) are sometimes produced in this 
way. In such cases the blood collects more in the veins and sinuses 
of the brain than in its arteries, for it does not receive enough force 
from the heart to keep it in full motion in these. This congestion 
may be only temporary, and ultimately lead to no serious results ; 
but in some instances I believe there does occur an event that has 
not been noticed by pathologists — namely, a coagulation of the blood 
in the sinuses, and a consequent permanent obstruction to the circu- 
lation through the brain. I have met with several cases correspond- 
ing more or less with the following description. 

A young female becomes anaemic, and after exhibiting various 
symptoms of feeble general circulation, with headache, drowsiness, 
and impaired sensorial functions, she suddenly gets worse ; passes 
into a state of stupor with dilated pupils, (sometimes varied by slight 
manifestations of delirium,) throbbing of the carotids, and partial 
heat of the head ; and at length dies comatose. On opening the 
head, a small quantity of serum is found under the arachnoid and in 
the ventricles, sometimes with a little lymph (in one case there was 
none.) The membranes are remarkably vascular, but the vessels 
most distended are the veins, and in the larger of these, as well as 
in the longitudinal sinus, there is a firm coagulum. In places, espe- 
cially at the torcular Herophili, this coagulum blocks the whole sinus, 
the fibrin being separated from the other constituents, and portions 
of it softened down into that opaque purilaginous matter which was 
long mistaken for pus, but which Mr. Gulliver has shown to be merely 
such a disintegration as stagnation in a warm temperature is able to 
effect, and is probably somewhat of the nature of fatty degeneration. 
These cases have been taken for instances of meningitis. No doubt 
inflammation may supervene in them occasionally, but in two cases 
that have fallen under my notice, there was no adhesion of the 
arachnoid deposit upon it, or other unequivocal mark of inflammatory 
action ; yet the fibrinous and bloody concretions in the veins and 
sinuses were most remarkable for their size and firmness. 1 (§ 213.) 

cold. To understand these facts, we must bear in mind that when the arteries are full 
and tense, they oppose their fulness and tension to each contraction of the heart, and 
that this resistance reduces the strength of each pulse in the vicinity of the heart, at 
the same time that it continues to propagate it to a distance ; hut that when the arteries 
are empty and loose, the heart squirts the blood into them in an unresisted jet, whose 
force is strong near the heart, but does not extend to distant arteries. Nothing is more 
common than to find the heart beating with a violence that is distressing to the patient, 
although at the same time the feet and hands are cold, and the pulse can scarcely be 
felt at the wrist. These incongruities are essentially connected with the morbid condi- 
tions present, namely, a reduced quantity of blood and defective tonicity of the vessels 
(2 123.) 

1 A wax model of the sinuses and membranes of one of these cases is in the museum 
at the London University College. Cruveilhier gives a drawing from a similar case, 
which, without sufficient reason, he considers as one of cerebral phlebitis. Andral men- 
tions a case of cerebral hemorrhage in connexion with ancemia; this was probably of 
the same kind. 



200 



AXiEMIA. 



It appears to me very probable that these affections originate in 
the encephalic congestion connected with the anaemia. Fibrinous 
concretions form on the transverse bands of the sinuses, and increase 
until they considerably obstruct the passage of the blood : this clearly 
accounts for the impaired state of the cerebral functions, amounting 
at last to coma. Reaction (§ 16) may take place, leading to deter- 
mination of blood, and even inflammation, and thus cause such 
symptoms of partial excitement as sometimes exhibit themselves ; 
bat neither during life, nor on examination after death, are the 
evidences of excitement so prominent as are those of obstruction and 
interruption to the cerebral functions. It must be remembered that 
in anaemia the fibrin of the blood is not diminished in the proportion 
of the other organic constituents, and it has besides a greater 
tendency to coagulate than in healthy blood (§ 207.) There is a 
variety of headache which often occurs in persons with scanty blood 
and feeble circulation, and which seems to have some connexion with 
these irregularities of the movement of the blood through the head. 
When this affection is accompanied by darkness under the eyes, and 
a dusky injection of the conjunctiva, it is clearly of a congestive 
nature ; and although increased by exertion and excitement, it is 
sometimes signally relieved by measures which equalize, as well as 
quicken the general circulation, as for instance the administration of a 
cup of hot tea, a draught of ether and ammonia, or by a warm bath. The 
sudden manner in which the headache ceases is accounted for by the re- 
storation of the circulation through the previously congested vessels. 

269. In anaemia of long duration the process of nutrition often 
suffers (§ 211,) but by no means uniformly. The cornea is some- 
times ulcerated ; probably because, being a non-vascular texture, it 
the more needs a highly nourishing plasma for its support. The 
nails and hair also are affected in consequence of the imperfect 
nutrition ; and in young subjects the bones are occasionally found 
to be deficient in their normal rigidity. In some instances the 
gums are spongy, and liable to bleed, and hemorrhage from both 
this source, and from the nostrils, are accidents of by no means 
unusual occurrence. The muscles become flabby and attenuated; 
wounds and fractures do not readily unite; and in some instances 
spreading ulcers and sloughy sores form spontaneously on the external 
surface. Emaciation is not, however, a constant result of anaemia; 
and it is not an unusual thing to see the most pallid subjects, 
(especially if females,) retain a considerable amount of fat. Drop- 
sical effusion into the cellular texture is a common result of anaemia, 
when either long continued, or aggravated by additional causes of 
disturbance to the circulation ; and slight inflammation of the pleura 
or other serous membranes then speedily produces copious exhalation 
into the closed sacs (§ 222.) The researches of Chossat on the effects 
of inanition on animals in some measure bear relation to this subject; 
for anaemia is the result of deficient nutrition (§ 63.) He found that 
defective nourishment notably reduced the weight of all the structures 
of the body, with the exception of those which belong to the nervous 
system ; these were wonderfully little diminished by it. This fact 
accords with the remarkable activity of this system often observed in 



PROGNOSIS — TREATMENT. 201 

persons who have been weakened by low diet and similar influences; 
and is perfectly explained by the manner in which the vessels supplying 
the nervous centres monopolize what blood there is, as pointed out in 
a preceding paragraph (§ 267.) This ascendency of nervous function, 
which was first a temporary result of irregular circulation, becomes 
however in time permanent from modification of structure ; and the 
condition which might have been obviated sooner by the adoption of 
measures calculated to regulate the flow of blood, assumes the fixed- 
ness and intractability of structural disease. Hence young persons 
who remain long in an anaemic state, are very liable to suffer from 
confirmed and incurable nervous affections. Even adult females who 
suffer from extensive and repeated losses of blood acquire a nervous 
susceptibility which they never afterwards lose. 

270. Anaemia, although ordinarily amenable to treatment, may yet 
in aggravated forms prove a formidable disease, and even be suddenly 
fatal through syncope (§ 71,) induced by some exertion or additional 
cause of exhaustion ; or it may more gradually lead to death by 
asthenia, or general failure of the vital powers, often attended with 
anasarca ; or by developing tuberculous (§ 211) or other cachectic 
diseases to which the individual may be predisposed ; or by the singu- 
lar affection of the head before noticed (§ 267;) or by other slower 
and less marked changes brought about in the nervous centres, and 
ending in paralysis, insanity, amentia, and epilepsy. 

271. Remedial measures. — Few disorders afford more striking 
illustrations of the power of medical treatment than anaemia, espe- 
cially that variety of the disease which was formerly called chlorosis. 
The ghastly appearance of the patient, often conjoined with an 
alarming amount of weakness, is well calculated to excite great 
alarm in the unprofessional observer, and the pathologist, too,.jnay 
well be excused for sharing in the apprehension, since he knows 
that the vital fluid which is essential for the sustenance of every 
function is so deficient and depraved that healthy life cannot go on. 
Experience, however, teaches that here the blood-making processes 
may be restored by the timely and judicious administration of certain 
remedies of the chalybeate class. In a few short weeks all that was 
faulty is repaired, and the death-like pallor of the countenance is 
changed to a ruddy hue. Most of the measures adapted to restore 
the deficiency of the red corpuscles of the blood in the anaemic state 
have been already specified elsewhere (§ 193, 216.) A nourishing 
diet, with as much animal food as the digestive powers of the patient 
can master, aided perhaps by the careful use of stimulants — tonics 
that best restore the appetite, and the powers of digestion and 
sanguification — secernents, if called for, to promote the natural 
excretions (§ 172 et seq. 191,) exposure of the patient to the pure air 
and light of heaven, as freely and as long as the strength and sensi- 
bility in the particular case will allow, — avoidance of fatigue, excite- 
ment, and all debilitating and exhausting influences ; — these constitute 
the principal points that are to be observed in the treatment. 

The adaptation of these plans of treatment to individual cases 
requires the exercise of much discretion, especially in proportioning 
the food to the power of digestion, and in selecting such a form of 



202 



AM MIA. 



tonic as will not irritate. Where it does not disagree, iron is 
unquestionably the best remedy ; but the preparation of it that is 
most suitable for exhibition varies considerably with the nature of 
the case. Where there is no particular fastidiousness of stomach, or 
tendency to headache and feverish excitement, its more active salts, 
the sulphate, sesquichloride, acid phosphate, and iodide are the best. 
The iodine in the iodide tends to keep the secretions free and improves 
the condition of the capillary circulation: on account of its liability 
to undergo decomposition it is best given in the form of syrup: under 
its use I have seen healthy ruddiness restored to chlorotic females in 
the space of three weeks. In many cases, however, iron cannot be 
so rapidly introduced as it is when these active preparations are 
used, for either the stomach is intolerant of the remedy, or the head 
suffers from the excitement before enough has been taken to produce 
the desired result. Here it will be found that if the weaker chaly- 
beates. such as the ammonio-citrate, the sesquioxide, the saccharo- 
carbonate and the acetate, be chosen, and a very small dose (as 
perhaps half a grain) be given at first, the remedy will be borne, and 
will eventually, although slowly, produce its beneficial results. One 
frequent reason for intolerance of iron, as well as of other tonics, 
even where their influence is greatly needed, is defective action of 
the excreting organs, evidenced by costive bowels, and scanty high- 
coloured urine. In these circumstances the blood, scarce as it is, is 
impure also, and the slightest use of a tonic may excite irritation, 
instead of improving the blood-making process. Eliminating remedies 
are therefore required, and those which generally answer best are 
effervescing saline medicines given in combination with iron, and 
conjoined with the use of a slight daily aperient of aloes or rhubarb. 
These act on the principle of saline chalybeate mineral waters, and 
they are eminently successful, not only in decided anaemia, but also in 
the numberless modifications of mixed weakness and faulty secretion, 
that are so commonly met with among the less industrious classes of 
society. By management of the kind above specified almost every 
anaemic patient may be brought to bear iron ; and the exceptional 
cases may be treated with calumba or cascarilla and ammonia, and 
small doses of iodide or bromide of potassium, which will strengthen 
the stomach, and equalize the circulation, and so prepare the way for 
the ultimate employment of the more powerful and proper remedy. 

Various other tonics may be advantageously combined with the 
iron in extreme cases of anaemia and debility, especially where these 
have been induced by hidden hemorrhage. Of these adjuvants 
quinine is the most important. M. Petrequin has recently recom- 
mended manganese as a useful addition to iron in the treatment of 
anaemia, and he urges in its favour that it is a natural constituent of the 
blood. I have in several instances prescribed the syrup of the iodide 
of iron and manganese (as prepared by some of our leading pharmaceu- 
tists) and it has answered very well, but whether better than a simple 
preparation of iron would have done, I am not prepared to say. 

The success of the treatment in anaemia becomes manifest, not only 
in the return of a healthy colour to the lips and skin, of size to the 
superficial vessels, and of strength to the pulse, but also by an im- 



EFFECT OF REMEDIES. 



203 



provement in all the functions, — breath, strength, digestion, etc. It 
is a curious fact, that the venous murmurs (§ 264,) although diminished, 
are not so in proportion to the apparent return of colour to the sur- 
face ; I have before given my reasons for considering these to be 
dependent on deficiency of albumen as well as of the red corpuscles. 
This does not accord with the opinion of Ml Andral, who reckons 
the vascular murmurs to be true exponents of the deficiency of the 
red corpuscles only : but this as a matter of observation loses weight 
from the erroneous notion which he, in common with Bouillaud, holds 
as to the seat of these murmurs. They believe them to be in the 
carotids only : several years since I satisfied myself, by numerous and 
varied experiments, that Dr. Ogier Ward's opinion, that the loudest 
murmurs are in the veins, is correct. 

272. Besides the above-named general measures, indicated in all 
varieties of anaemia, there are temporary measures required by 
particular cases ; on the one hand, to prevent faintness or excessive 
prostration (§ 262 ;) on the other, to subdue nervous excitement 
(§ 265,) and counteract the congestion in the head, which we have 
remarked upon as likely to occur (§ 267.) Diffusible stimulants, 
such as carbonate of ammonia, valerian, sumbul, ether, wine, apd 
spirits, often prove useful as temporary means of obviating extreme 
weakness ; and in such a state all exertion, even sometimes the 
merely assuming the erect posture, must be avoided. In anemia 
following sudden and excessive losses of blood, as the heart and 
brain have not then become used to the scantiness of the circulating 
fluid, this is especially necessary, and if it be not observed, fatal 
syncope may be induced. Symptoms of nervous excitement ( § 26) 
require sedatives and narcotics ; such as hydrocyanic acid, hyoscyamus, 
belladonna, and conium ; whilst those of nervous depression call for 
the use of such stimulants as are found to excite the nervous energies, 
as for example the fetid gums, oil of turpentine, (especially given in 
enema,) strong tea and coffee, cantharides, strychnia, and electricity 
§ 130, 155.) But inasmuch as these very symptoms seem to depend 
on the irregular distribution of the little blood left in the body, they 
will be the most effectually relieved by removing this irregularity 
through the unremitting maintenance of warmth in the external 
surface and extremities, aided by occasional friction, and rest in the 
horizontal posture, varied with such gentle exercise as the patient 
can bear; the breathing of pure air, and the judicious use of tepid 
or cold sponging, or the shower-bath, especially directed on the head 
and spine (§ 124) will greatly assist in contributing to the same end. 
The symptoms of decided cerebral congestion and obstruction have 
generally been treated by antiphlogistic remedies, but with question- 
able advantage. I have found more benefit to result from a mild 
stimulant and tonic plan, together with the use of more or less 
powerful derivants, purgatives, and saline diuretics. Such measures 
commonly answer best in the congestive headache which often troubles 
anaemic subjects. Depletion is often earnestly called for by the 
patient ; but it should be avoided as much as possible ; where abso- 
lutely, required from the urgency of the symptoms, cupping to the 
nucha, or leeches to the temples, or, what is still more effectual, one 



204 



ANJ3MIA. 



or two leeches applied to the interior of the nostrils, will answer 
best. Persons who have suffered long and severely from anaemia, 
especially induced by excessive and repeated losses of blood, or by 
menorrhagia or uterine hemorrhage, or by inordinate lactation, do 
not lose their nervous symptoms in proportion as their blood is re- 
stored ; and this I am inclined to ascribe to some degree of structural 
change having ensued, as suggested above (§ 268,) a more permanent 
exaltation of the nervous functions being thereby maintained. The 
treatment necessary in such cases is also of an enduring kind, avoiding 
all causes of nervous excitement, and using those various means, 
medicinal and regiminal, which have been formerly recommended as 
of service in reducing nervous excitability (§ 128, 155.) Of the 
medicines adapted to such cases, the metallic tonics are most deserving 
of mention ; especially the valerianate and sulphate of zinc, the 
nitrate and oxide of silver, the sulphate of copper, and according to 
Professor Simpson, the sulphate of nickel. 

PARTIAL ANEMIA. 

273. We have the means of becoming acquainted with deficiency 
of. blood in a part of the body in more diversified degrees, than we 
have of studying deficiency in the whole : in every degree the result 
is an impaired state of the functions, from mere weakness down to 
total suspension and death. Thus temporary pressure on the chief 
artery of a limb soon causes numbness, weakness, and reduction of 
temperature. The same effects result in a yet more marked degree, 
when an artery is tied in cases of aneurism, and they are gradually 
removed as the supply of blood is restored through collateral vessels. 
In some such cases, the supply of blood is insufficient to maintain the 
vital properties of the part; then chemical affinities prevail (§ 50.) 
decomposition ensues, and the structure becomes gangrenous and dies. 
A similar result ensues when the arteries of a limb are obstructed 
by ossification and coagulation, as occurs in senile gangrene. This 
event may be produced artificially in animals in forty-eight hours, by 
injecting charcoal powder into the artery of a limb, the capillaries 
being thus totally obstructed (Majendie.) A sudden obstruction of 
an artery sometimes occurs in connexion with endocarditis, and other 
diseases of the heart, and Dr. Kirkes has pointed out that this 
probably results from a mass of fibrin being detached from the in- 
terior of the heart, and being then conveyed in the arterial current 
until it blocks up an arterial branch, and so induces partial anaemia 
by arresting the circulation there ; first there is suspension of function, 
and subsequently atrophy, softening, or gangrene. This effect has 
been observed in the brain, in the kidneys, in the spleen, and in the 
limbs, and it affords a satisfactory explanation of the sudden attacks 
of hemiplegia, or of loss of pulse and feeling in limbs, of which I 
have known several examples. 1 It is most probable that inflamma- 
tion and other lesions sometimes terminate in gangrene, by obstructing 
the circulation, and thus depriving the tissues of a principle indis- 
pensable to the maintenance of life. 

Many other instances of partial anaemia, short of the extreme cases 



1 Med Chir. Trans., 1853. 



PARTIAL — EXAMPLES AND EFFECTS. 205 

above noticed, might be cited — thus the perfectly pallid and bloodless 
condition of the lingers of persons of weak circulation, after cold 
bathing or long exposure to cold, is a very good example. The 
vessels are in these so contracted as quite to exclude the blood, and 
the finger is of waxy whiteness, cold, numb, and almost powerless. 
A similar condition sometimes obtains in the entire lower extremities 
in inclement seasons. In individuals liable to be affected in this 
way, a warm temperature often occasions faintness, and even hemi- 
plegia, by producing deficiency of blood in some part of the nervous 
centres. In fact many of the symptoms present in those suffering 
from general ancemia or weak circulation, arise from deficiency of 
blood being more marked in some parts of the body than in the rest. — 
The functions of organs also suffer from the same inequality of dis- 
tribution of blood. In one subject the skin is dry, and perhaps 
rough and scaly, from paucity of blood supplied to the surface. In 
another the mucous membranes are principally affected, and dryness 
of the mouth, fauces, and nostrils, and consequent irritation of these 
parts, with indigestion and costiveness, may result. In a third, the 
synovial membranes lack their due supply, and crepitation and stiff- 
ness accompany the motions of the joints. It is where the general 
circulation is weak that pressure is most liable so to interrupt the 
circulation of any part, as speedily to deprive it of life, so that it 
ulcerates, or sloughs, as in the instance of bed sores. 

Softening, wasting, and degeneration of textures, are also effects 
attributable to continued defective supply of blood. The former is 
exemplified in softening of the brain and. of the heart, occurring in 
connexion with ossified arteries: wasting, in the atrophy of parts 
subjected to continued pressure ; and degeneration in the fatty change 
of the heart and other muscular structures, consequent on impeded 
supply of blood. The areas senilis or arciform degeneration of the 
iris, appears to result from the pressure of the eyelid, which quickens 
the degeneration of that part. Partial anasmia is concerned in pro- 
ducing many changes of structure that arise under various circum- 
stances. Deficient supply to secreting organs necessarily impairs the 
amount and quality of their secretions (§ 159.) 

The treatment proper for partial anosmia comprises not only 
measures that restore the supply of blood, but also such others as 
maintain and equalize that supply by increasing the quantity and 
improving the quality of the fluid in general. Thus, while the appli- 
cation of heat, stimulant frictions, and the employment of exercise, 
are practised, to bring back blood into the anaemic part, the remedies 
for general weakness and anaeinia (§ 271) should be brought into 
action to maintain a more constant supply, and to prevent other parts 
from suffering in turn from the deficiency. As the duration of partial 
anaemia is generally of a more temporary character than is that of 
the general disease, the most efficient remedies are such as act 
promptly, for instance, stimulants, generous diet, and various me- 
chanical and other appliances calculated to quicken the movement of 
the circulation. One expedient for accomplishing this latter object 
deserves especial mention on account of its great utility under par- 
ticular circumstances ; I allude to the use of the vulcanized India- 



206 



HYPEREMIA OR POLYJEMIA : EXCESS OE BLOOD. 



rubber water-cushion to prevent the pressure which occasions bed 
sores. The same cushion filled with hot water likewise affords a 
ready means for applying dry warmth to the skin and extremities, 
when the natural temperature fails, and thus it may aid in the coun- 
teraction of local anaemia. 



SECTION II. 



HYPEREMIA OR POLYiEMIA I EXCESS OF BLOOD. 

274. Too much blood in the system, or in a part, is a most frequent 
cause of disease. It implies an undue distention of the vessels which 
contain it ; and a modification of the properties of these vessels, and 
of the heart, is almost constantly a concomitant of this morbid condi- 
tion. The chief vital properties of the heart and vessels are irritability 
and tonicity ; excess (§ 114, 121) and defect (§ 116, 123) of these 
form important elements which modify the effects of excess of blood : 
and thus is synthetically suggested a distinction (long recognised as 
most valuable in practice) of the active or sthenic, and the passive or 
asthenic, hyperemia: this distinction is applicable to both general and 
partial excess of blood. Another variety of hyperemia is character- 
ized by an altered or perverted action of the vessels ; this is chiefly 
seen where the affection is confined to a part, and includes that singu- 
lar and complex condition — inflammation. An enumeration of these 
important proximate elements of disease (§ 107) is given in the fol- 
lowing table. It is not meant that the diseased conditions specified 
are always separate, or that they consist merely of the elements stated ; 
but these are their most distinguishing features, and especially impor- 
tant in regard to treatment. 



General=Plethor 



Hyper- 
emia : 
Excess of 
blood. 



i 



"with motion increased=Sthenic "] results. 



dinrinished=Asthenic 



J 



Local ■{ 



' with, motion diminished=Congestion 

— — increased=Determination of blood J 

— — partially increased, 

[ partially diminished=Inflammation. 



Hemorrhage. 
Flux. 

Dropsy, &c. 



SECTION III. 
PLETHORA — GENERAL EXCESS OF BLOOD. 

275. As general anaemia may arise from defective formation or 
excessive expenditure of blood, so general plethora may proceed 
either from too much blood being made, or from too little being ex- 



CAUSES — EFFECTS — STHENIC — AND ASTHENIC. 



207 



pencled. In either case, the blood accumulates and fills the heart and 
blood-vessels beyond the usual degree. But this implies a certain 
activity and health in the processes of digestion and assimilation, 
and also a freedom from any considerable local disorder. A person 
with weak digestion rarely becomes plethoric; and one who suffers 
from a local ailment ^is commonly warned by an aggravation of this, 
before the fulness can become general to any great extent. 

276. The persons most liable to become plethoric are those who 
are overflowing with health; who have a good appetite, and indulge 
it, without paying sufficient regard to exercise and to the excernent 
functions; and whose digestive powers are in full activity. The blood- 
making process is with them ever in excess ; the vessels get more and 
more filled; and their fulness becomes manifest in the red face, dis- 
tended veins and large pulse: the heart is excited and labours with 
its load, especially on any muscular exertion being made ; hence pal- 
pitation and short breath ensue, with somnolency and indisposition to 
exertion; but these may attract no immediate notice, and merely lead 
to inactive habits. The state of plethora, thus gradually induced, 
may be extreme, without any of the vital functions materially failing, 
and yet the subject is on the brink of various maladies. It is well 
if some great secreting organ is first excited under the high pressure, 
and the system gets relieved through a free discharge, as when a mu- 
cous or bilious diarrhoea sets in ; or if some unimportant and convenient 
set of blood-vessels gives way, as when epistaxis, or bleeding piles 
occur; if one of the great secreting organs, as the liver or the kidneys, 
fail in its proper function (§ 170, 254,) when a bilious attack, jaundice, 
or a fit of gout or gravel, is the consequence. Any of these results, 
by establishing a perceptible ailment, serves to disturb the dangerous 
ease of the plethoric; and by rendering necessary a temporary disci- 
pline, saves him from the worse consequences of plethora — apoplexy, 
or structural disease of the heart, or of the great vessels, lungs, kid- 
neys, or liver. 

277. Besides the conditions already noticed, there are other circum- 
stances which may induce plethora. The diminution of a natural or 
habitual excretion or loss of blood, the drying up of a long established 
sore or issue (§ 270,) or the removal of a limb; all of these diminish 
the expenditure from the system, without impairing the blood-making 
process, and so often become causes of plethora, if no local disorder 
be excited before the vessels in general reach a plethoric tension. 

278. The distinction of plethora into sthenic and asthenic depends 
upon the different degrees of the strength and irritability present in the 
motor fibre; this we have already noticed as an ultimate element of 
disease (§ 110 and 120, et seq.) Where the irritability and tone of 
the heart and arteries are in full amount, the increased quantity of 
blood excites these properties to the utmost. Apart from absolute 
disease, the vital functions are active and energetic in proportion to 
the quantity of blood which the respective organs receive; when the 
supply is abundant, the heart's action and the arterial pulse are strong 
and regular; the secretions are copious; sensibility is keen; contrac- 
tility powerful and in good tone; animal heat well sustained; and the 



208 



PLETHORA — STHENIC. 



mental and bodily powers generally vigorous and active. Bat when 
the quantity of blood is augmented beyond this, plethora tends to dis- 
ease; the heart's action gets over-excited; the pulse is frequent, as 
well as strong and hard; the face is florid and flushed, and the heat 
almost feverish; the capillaries of secreting organs and surfaces are 
variously disordered, sometimes excited to exGessive secretion, or 
sometimes beyond, to a state of fulness bordering on hemorrhage or 
inflammation; then occur bilious attacks, hsernatemesis,lithic acid gra- 
vel, strong and acid urine, and various forms of sthenic gout: the sensi- 
bility and sensorial powers may be stimulated by the rapid flow, or 
they may be diminished by the pressure of the blood on the nervous 
centres. Attacks arising from these different effects of plethora may 
occur again and again, alternating with intervals of unimpaired health, 
but in time the tendency to disorder becomes greater in consequence 
of the structures and functions recovering less perfectly in the inter- 
vals, and if the plethora be continued, it gradually loses its sthenic 
character, and lapses into the less active variety. If the plethoric 
state is moderate enough to last for some time without producing im- 
mediate disaster, the nutritive function eventually gets to be affected. 
Some of the superfluous nourishment may be deposited in fat, which 
deposition is another safety-valve to the plethoric: but even this 
throws an additional burden on the heart and blood-vessels, which 
are therefore the more strained and oppressed, and are among the 
first of the textures to exhibit structural changes, in the form of hy- 
pertrophy, valvular disease, atheromatous patches leading to dilatation, 
aneurism, &c. In this way organic disease may issue out of the con- 
tinued excitement of sthenic plethora. 

279. Sthenic plethora is the form which commonly affects the young, 
the active, and those who are in the prime of life or of sanguine tem- 
perament (§ 41.) It comprehends a rich state of the blood (§ 184,) and 
an active condition of the nutrient function (§ 195.) Its tendency is 
to cause general febrile excitement, active hemorrhages, fluxes, and 
inflammations. 

280. In asthenic plethora there is a want of contractility (§ 116) 
and tone (§ 123) in the motor fibre. The heart and other organs, in- 
stead of being excited by the augmented quantity of blood, are op- 
pressed by its load. The pulse may be full, but then it is slow; more 
commonly it is frequent and irregular or unequal. There is some- 
times- a tendency to faintness alternating with palpitation; physical 
examination indicates that the heart is enlarged by the accumulation 
of its contents beyond what it can expel. The face is purple rather 
than red ; the veins are generally distended ; sometimes the extremi- 
ties are apt to become cold. Most of the vital functions are sluggish, 
and imperfectly or irregularly carried on. The bowels are torpid; 
the urine is scanty, high-coloured, or turbid; sensibility is blunted, 
muscular power low, and the mental faculties dull, with lethargy or 
somnolency; the spirits are often depressed, and the activity alto- 
gether reduced. 

281. Asthenic plethora affects principally those who are weakened 
by age, excesses, or previous disease, and in whom the excreting or- 
gans act imperfectly; such imperfect action is a cause, as well as a 



ASTHENIC — SYMPTOMS 



209 



consequence of plethora. In fact it is the increasing impurity of the 
blood that tends to convert the sthenic into the asthenic form (§ 278.) 
It is when the blood is not properly purified of the effete matter which 
forms in it, whether it be stagnant or in motion, that it fails to excite 
the functions of organs in a regular manner, so that they in conse- 
quence become oppressed, sluggish, and disordered, and the morbid 
condition results in cachsemia as well as hyperemia. Asthenic ple- 
thora tends to produce congestions, passive hemorrhages, fluxes and 
dropsies; and if continued, structural changes in some organs, such 
as dilatation of the heart, enlarged liver, varicose veins, &c. Con- 
gestion of the brain, with apoplexy or palsy, headache, or other symp- 
toms of disturbed cerebral function, is sometimes produced ; or if there 
be any organ, the vessels of which are weak from past or present 
causes (§ 31, 32,) this organ is liable to be the first to suffer. 

282. The symptoms of asthenic plethora hitherto described are 
chiefly expressive of a depressed or oppressed state of the functions. 
Sometimes, however, there arise others betokening excitement or re- 
action of an irregular kind. The pulse becomes quickened, and often 
irregular; the skin is hot or partially perspiring ; sickness and vomiting 
may occur; the tongue gets much furred, and sometimes brown and 
dry : the excretions are defective, unusually offensive, and often changed 
in appearance; the complexion becomes dusky, the eyes suffused, the 
mental faculties blunted by lethargy or confused by low delirium. 
This is a kind of congestive fever, such as is described by Dr. Barlow 
as a result of reaction from asthenic plethora. It is possible that this 
description may have been drawn from cases in which, besides as- 
thenic plethora, some morbid poison (§ 258) has been in operation; 
but many of the symptoms named may be fairly traced to a congestive 
fulness of the blood-vessels, combined with an impaired action of the 
excreting organs (§ 70, 171, &c. ;) and consequently, with the diseased 
condition of the blood, which we have described to arise from imper- 
fect excretion (248, et seq.) The mere stagnation or imperfect motion 
of the blood will prevent it from properly undergoing the process of 
purification, and the elimination of its decaying materials through the 
instrumentality of respiration and excre.tion: hence it becomes loaded 
with urea, lithic and lactic acids, and other effete matters which unfit 
it for its proper uses, and irritate and disorder the organs through 
which it passes. The process of reaction, or febrile excitement, 
which occurs in cases of asthenic plethora, is sometimes more dis- 
tinctly connected with a specific condition of the blood, as in the case 
of gout (§ 254,) rheumatism (§ 251,) and various cutaneous diseases, 
which assume generally the atonic or asthenic form. 

283. Remedial Measures. — The means already described as useful 
in effecting a reduction of excess of red corpuscles (§ 192) and fibrin 
(§ 214) are also suitable for the earlier and simpler states of plethora, 
in fact, in these states, the blood usually does exhibit this very ex- 
cess, for which blood-letting, evacuants, and abstinence are the chief 
remedies. The propriety of blood-letting in extreme degrees of ple- 
thora is evinced by the extent to which it may be carried without 
causing faintness. Thus Dr. M. Hall found, that in patients suffering 
congestive apoplexy, from forty to fifty ounces might be drawn with- 
14 



210 



PLETHORA — RESULTS. 



out producing syncope; whilst in acute inflammations, the tolerance 
is usually less by about ten ounces. But it is not necessary to employ 
blood-letting to this extent in simple plethora, even when in an ex- 
treme degree; the object is then not so much to cause faintn.ess or a 
sudden impression, as to relieve the extreme tension of the vascular 
system, and thus to afford the secreting organs an opportunity of ac- 
complishing the remainder of the cure. It is rarely desirable to draw 
more than twenty ounces of blood, and in many instances cupping to 
a small amount over an organ especially congested, will suffice. The 
beneficial effects of blood-letting are sometimes immediately manifest, 
although they vary somewhat in the two varieties of the disease. In 
the sthenic kind, the pulse becomes softer, weaker, and less frequent; 
in the asthenic, it often improves in strength and regularity, and 
sometimes rises to a natural frequency. In simple and recent cases 
of both kinds, a moderate blood-letting, with due avoidance of the 
causes of the plethora (so far as that can be accomplished,) and the 
continued use of a little aperient and saline diuretic medicine, will 
complete the cure. 

284. But if the plethora have lasted long enough to produce some 
of its ulterior effects (§ 282,) blood-letting may be an insufficient, nay, 
in some instances, even an unfit remedy. In both kinds of plethora, 
medicines which increase the excretions are generally indicated, and 
the diet must be much restricted; but the particular mode in which 
the special aim of treatment is to be carried out, varies greatly in the 
separate forms. 

285. In sthenic plethora, not only is the blood in excess, but so 
also are the irritability and tone of the moving fibre. Here, then, 
besides removing the excess of blood, sedative and relaxing remedies 
(§ 115, 122) are indicated. Antimonials, salines, digitalis, aconite, 
and hydrocyanic acid, conjoined with a cool regimen, and spare diet, 
are found to be serviceable ; these are often useful in the treatment of 
sthenic plethora. Lemon juice may be ranked as a medicine of a 
lowering kind ; it distinctly reduces the strength and frequency of 
the pulse. The same remedies combined with mercury, coichicum 
and other like agents, fulfil also another indication; they augment 
excretions which are defective in consequence of an over excited 
state of the capillary circulation, bordering on hemorrhage or inflam- 
mation. If any part should especially suffer, local blood-letting may 
be requisite. 

286. In asthenic plethora of long duration, on the other hand, al- 
though blood-letting may relieve, it does not recall the lost tone of 
the over-distended vessels. Tonics (§ 124,) and even stimulants (§ 119) 
may be necessary at the very time that blood is drawn and evacuants 
used; and such treatment as is calculated to restore the impaired 
functions of digestion and secretion, and to improve the depraved con- 
dition of the blood may be required to be long persevered in (§ 174.) 
In such cases, the prolonged use of alterative aperients and diuretics, 
such as mild mercurials, rhubarb, aloes, senna, salines, taraxacum, nitric 
acid, and iodide of potassium, may prepare the way for the ultimate em- 
ployment of such tonics as calumbo, bark and iron. In these cases, 
the mineral waters of Cheltenham, Leamington, and Llandrindod, in 



r LOCAL HYPEREMIA — CONGESTION. 



211 



this country, of Carlsbad, Maricnbad, and Homburgin Germany, and 
of Vichy in France, are often of great service; first the more saline, 
which are aperient and diuretic, and afterwards the more chalybeate, 
which, although tonic, usually contain enough saline matter also to 
keep the secretions free. Some waters of the latter class, as those of 
Bath and Wiesbaden, tend to excite torpid and plethoric habits to a 
critical reaction, thus often bringing on a regular fit of gout (§ 254.) 

The diet needs to be well regulated in all cases of plethora. In 
the sthenic kind it should be spare, so as to diminish the materials 
from which the blood is formed (§ 193.) Little or no animal food, 
or that only which is of the lightest kind, such as white fish and chicken, 
should be used. A moderate quantity of bread should be taken, and 
if the appetite and digestion be good, a liberal allowance may be 
made of vegetables and fruit. The "cure de raisins, 77 in which the 
diet is exclusively grapes and a little bread, is well adapted for cases 
of sthenic plethora. Fermented and spirituous liquors must be wholly 
avoided. It must, however, be borne in mind that plethora is an ha- 
bitual condition of the system, rather than an attack of positive dis- 
ease, and happening, as it may do whilst the appetite is good, and 
whilst the functions of digestion and assimilation require a fitting em- 
ployment, the subject of it is not to be starved by a diet fit for a pa- 
tient with fever or inflammation. The plan should therefore be one 
of moderation, which can be persevered in, rather than one of extreme 
abstinence which might soon injure the health. In asthenic plethora 
there is even more need for caution in the reduction of the diet : and 
care should be taken to avoid rich and heating articles of food, rather 
than such as are of a nutritious quality. Even fermented liquors of 
a light kind may be advantageously used in moderation, if previous 
habits have established a need of them. As there is commonly much 
functional weakness of the digestive as well as of other organs, it is 
important that such adjuvants as possess no ulterior injurious opera- 
tion should be employed. Regular exercise in the open air, so far 
as the strength will permit, is likewise an important aid in restoring 
tone to the system, and in improving the condition of the blood. 



SECTION IV. 
LOCAL HYPEREMIA— EXCESS OF BLOOD IN A PART. 
1. WITH MOTION DIMINISHED — CONGESTION. 

287. The true nature, and the distinctive characters, of congestion, 
or local hyperemia with retarded motion, may be conveniently traced 
through the several causes that induce it, all of which agree in com- 
bining the conditions here expressed in the definition of congestion, 
excess of blood in the vessels of a part, with diminished motion of that 
blood (§ 274.) We have already seen that portions of the vessels, and 
even the heart itself, become congested in asthenic plethora (§ 281;) 
but then it is as a portion of a more general disease. We have now 



212 



LOCAL HYPEREMIA — CONGESTION. 



to consider the causes and phenomena of congestion of blood in a 
part, which may occur independently of general disease. 

288. The word congestion means a heaping together, and conges- 
tion of blood is an accumulation of blood in the blood-vessels of a 
part. The main and essential seat of congestion is in the capillaries, 
but it may extend to the veins, or as we shall presently see, may 
even commence in them. The arteries, however, are not enlarged, 
and this is the important feature which distinguishes congestion from 
determination of blood, and inflammation. Blood-vessels become 
congested, or unduly distended with blood, when their proper elas- 
ticity and tone are overcome ; and this may happen because an ob- 
struction in the veins prevents the free escape of blood from them; 
or it may happen because the coats of the vessels themselves are 
weakened, and therefore yield to the pressure of the blood trans- 
mitted to them. The chief causes of congestion may then be classed 
under these two heads: — 1. That of venous obstruction; and, 2, that 
of atony of the vessels, (capillaries and veins.) We propose to notice 
under these two heads various instances of congestion, which will 
serve farther to explain and practically illustrate the subject. It is ob- 
vious that in congestion from either of these causes, as the blood accu- 
mulates in the part, its motion will diminish; for as the great source of 
that movement is the force transmitted from the heart through the 
arteries, so long as the arteries remain unenlarged, the force which 
the enlarged capillaries and veins receive, will be reduced in conse- 
quence of being expended upon their greater area. 

289. (1.) Congestion from venous obstruction. — When an arm is 
bound up for venesection, the veins are compressed more than the 
arteries. Hence the veins swell, then the fingers become red, and 
after a few minutes purple, and the whole limb is swollen from the 
congestion of blood in its vessels. Jn like manner, cold applied to 
the surface of the body affects and contracts the veins more promptly 
than the arteries which lie deeper, and the capillaries speedily be- 
come congested, as is evidenced by the purple colour of the hands 
and face. Gold also impedes the circulation by increasing the adhe- 
sion of the fluid to the walls of the tubes, a mere physical operation, 
first pointed out by Poisseuille;-and probably also by diminishing the 
activity of those chemical changes which assist the circulation in the 
capillaries. Congestions are caused in internal organs by obstruc- 
tion of the veins leading from them. Thus congestion of the brain 
may be produced by a tight stock or cravat (§ 51,) or by a tumour 
pressing on the jugular veins. Efforts of straining (§ 64,) coughing, 
holding the breath, and asthmatic paroxysms, which impede the flow 
of blood through the lungs, cause congestion in various parts. Dis- 
ease of the valves of the heart, which prevents the blood from passing 
onwards through it, produces fulness of the veins and of the capil- 
laries in both the pulmonic and systemic circulation. Tubercles in 
the lungs cause congestion of these organs. Obstruction to the 
transit of blood through the liver causes congestion in the abdomen. 
The characteristic of congestion beginning with the veins is, that the 
veins as well as the capillaries are distended : this appearance is ob- 



CAUSES AND VARIETIES. 



213 



vious during life in cases of aneurism, or any other kinds of tumour 
compressing the veins of the neck; and after death in the full arbo- 
rescent appearance of the veins in the congested part. Certain dis- 
eases of the organs of respiration, especially extensive emphysema ot 
the lungs, in which the efforts of expiration predominate over those 
of inspiration, cause congestions, not merely by opposing the return 
of blood through the veins, but also by lessening that suction influ- 
ence which serves to promote its flow towards the pulmonary capil- 
laries at each inspiration. It has been pointed out by M. Berard, 
(Arch. Gen. de Med., Jan. 1830,) and by Mr. A. Shaw, (Med. Gaz., 
July, 1842,) that the circulation in the liver during health, is to a 
certain extent dependent on this same action; and it may be inferred 
that the diminution of its power where there is extensive vesicular 
emphysema affords some explanation of the hepatic congestion that is 
so commonly combined with this pulmonary lesion. 

290. (2.) Congestion from atony of the vessels. — This is seen in a 
great variety of cases. In some of these the atony of the vessels 
(§ 123) affects the whole system, as is illustrated in extreme debility, 
adynamic fevers, and the sinking which precedes death. The heart 
then acts feebly, and without sufficient force for the propulsion of the 
blood through the whole circuit of vessels; these therefore yield from 
want of tone, and they do so most where they are the least provided 
with tonic fibres; that is, in the capillaries and veins, and especially 
those of parenchymatous organs. Here accordingly the congestions 
appear. The blood gravitates chiefly in parts that are the lowest in 
position in the body; the vessels of these, in their weak state, yield 
to the accumulating blood. This occurrence of congestion in under- 
most parts (hypostatic) is the distinctive character of the presence of 
weakened vessels. From this cause the posterior parts of the lungs, 
intestines, and integuments, are commonly found much congested 
after long lying in the recumbent posture. 

291. In other cases the weakness is local, and does not affect the 
vessels generally, the weakening influences being applied to some 
vessels only. Over -distention is a common cause of congestive weak- 
ness of vessels. Thus after long continuance of the body in one po- 
sition, the lower vessels yield to the gravitating force (§ 51) of the 
blood, and become congested. On this account the feet swell after 
long standing or walking, especially in warm weather. A continued 
stooping posture, or lying with the head low, may occasion conges- 
tion of the brain, headache, giddiness, and confused vision, and may 
prove an exciting cause of apoplexy. Remaining long in a standing 
or sitting position, often causes congestion in the hemorrhoidal veins, 
liver, uterus, &c. Where the circulation is feeble, and the tone of 
the vessels weak (§ 123,) these causes of congestion operate more 
readily and more permanently than where the circulation is vigor- 
ous; yet these congestive affections, the mere result of weakness, are 
often mistaken for inflammations. Many of the pains and ailments 
of delicate females are of this nature; and although temporarily re- 
lieved by depletory measures, are tp be permanently relieved only 
by tonic means (§ 124,) which promote the vigour and equality of the 
circulation. 



214 



LOCAL HYPEK2EMIA — CONGESTION. 



It must be born in mind that congestion, mechanically induced, 
when it lasts long, may so weaken the vessels by over-clistention, as 
to be continued after the original cause of the condition has ceased 
to operate. Thus congestion of the brain or lungs brought on by 
a paroxysm of dyspnoea, or of coughing, or by violent straining (§ 64,) 
may not subside with the cessation of the effort; giddiness, headache, 
pain, and dyspnoea, commonly remain for some time after such attacks. 

292. In considering the operation of cold as a cause of disease, we 
had occasion to notice that it chiefly operates by constricting the 
vessels of the surface and extremities, and thus throwing the blood 
inwardly, causing internal congestions by intropulsion (§ 77.) If 
this condition is continued long, the tone of the internal vessels be- 
comes impaired, and the congestions do not cease on the restoration 
of warmth to the surface. Thus a permanent congestion in the lungs, 
liver, kidneys, or mucous or serous membranes, whichever happens to 
be predisposed to the state, may result; and this congestion may dis- 
order the function of the part in various ways, or may lay the foun- 
dation of inflammation. 

293. Malaria (§ 82,) and the influences which produce continued 
and exanthematous fevers (§ 93,) seem to have a similar congestive 
effect with external cold, but it is not so easy to explain how they 
operate, unless by a directly paralyzing influence on the tonicity of 
the vessels, or by arresting the chemical changes which should take 
place in the capillaries. The cold stage of these diseases exhibits in 
a high degree the marks of intropulsive congestion; and it is well 
known that in ague the congestive enlargements of the liver and 
spleen are among the most remarkable phenomena exhibited (§ 191.) 
The congestions that are set up in the febrile stages of fevers, seem 
to be the chief causes of their inflammatory complications. 

294. Another cause of congestion is over-excitement of the vessels. 
It is well known that when a part has been inflamed, the vessels often 
remain dilated for some time, although the signs of true inflammation 
are no longer present. This is well seen in the conjunctiva, the 
throat, and the skin, and in certain ulcers; it is also exemplified by 
some internal organs. The liver and stomach present many signs of 
congestion after the excitement of stimulant drinks (§ 56.) We may, 
however, with the microscope, trace the production of congestion by 
stimulation apart from inflammation. 

•When a slight irritant, as a weak infusion of capsicum, is applied 
to the web of a frog's foot, it first causes a slight and very brief con- 
traction of the vessels, chiefly of the arteries (§ 120;) then quickly 
follows enlargement of the same with very rapid motion of their con- 
tents: if the application has been very slight, the vessels gradually 
contract after awhile, and return to their natural size. But if the 
stimulant application be repeated several times, so as to prolong the 
determination of blood into the part, the vessels do not then uniformly 
contract. The arteries indeed shrink, but the capillaries and veins 
remain dilated, and thus illustrate completely the conditions ex- 
pressed in the definition, excess of blood with diminished motion 
(§ 287.) This dilated state of the capillaries and veins must be partly 
ascribed to their losing tone after excitement (§ 123,) more than arte- 
ries do ; but the process which I have been describing is accompanied 
by changes within the vessels also ; numerous pale corpuscles adhere 



CAUSES — OVER-EXCITEMENT. 215 

to the sides of the capillaries, and so impede the current, and cause 
congestion by obstruction. Whenever the stimulus applied has been 
very strong, this obstruction amounts to complete stagnation, and many 
highly enlarged vessels appear filled with stagnant blood, or rather 
with an accumulation of red corpuscles entangled in the coherent pale 
ones. For this reason, the vessels in which the blood is stagnant, are 
of a deeper red than the others, the red corpuscles being arrested 
in them whilst the liquor sanguinis passes on. Mr. Wharton Jones 
has also observed that when the blood thus stagnates, the red cor- 
puscles adhere together in piles or rouleaux, as he had previously 
observed to be the case with blood out of the vessels. 1 

295. All that has been now described belongs to congestion, and 
there can be little doubt that the intense and deep redness sometimes 
seen in congested parts, is principally caused by the absolute stagna- 
tion of red corpuscles in the vessels. We shall hereafter see that a 
similar congestion and stagnation occurs also in inflammation, and 
may be the only change left by it that can be observed after death, 
if the inflammation has not existed long enough to produce its other 
more characteristic results. It is for this reason impossible to dis- 
criminate between recent inflammation and some forms of congestion, 
by direct anatomical characteristics. 

296. Congestion occurs in various organs and membranes when 
their proper secretions are arrested, or suddenly diminished (§ 167.) 
It is very probable that the passage of blood through a secreting 
organ or surface is promoted by the chemical changes which this 
fluid usually undergoes therein according to the law of osmotic force 
resulting from chemical action, noticed by Professor Graham [Pro- 
ceedings of Royal Society, June, 1854.) If therefore the chemical 
affinities of the blood, or of a secreting organ, be deranged, this mo- 
tive power may be wanting, and congestion of blood and deficient 
secretion may be the simultaneous result. It is difficult, however, to 
determine whether the congestion is, in the first instance, the effect 
or the cause of the defective secretion; very probably it stands in 
both relations: at least this is the most convenient view to take of the 
matter for practical purposes. Thus measures which increase the se- 
cretion (§ 172,) will often remove the congestion; and those which 
relieve the congestion, generally restore the secretion. There is no- 
thing in this incompatible with the principles already laid down; for 
the free flow of a secretion helps to unload the distended blood-vessels; 
and whatever relieves those vessels from their congested state, tends 
to restore that freedom of circulation through them, which best mi- 
nisters to the secreting process. And if, as just now surmised, the 
chemical changes involved in the secreting process aid in effecting 
the passage of the blood through the capillaries, the activity of the 
secretion will tend to re-establish the normal state of the circulation. 

297. In the first edition of this work, I alluded to some cases of 
congestion which had not then been traced to any of the causes above 
specified, although it was not improbable that farther investigation 
might succeed in tracing them to some of those causes. Thus when 
the blood does not undergo its proper changes in the lungs (§ 234,) 
its passage through these organs is partially impeded, and it accumu- 

1 Med. Chir. Trans., 1853. 



216 



LOCAL HYPEREMIA — CONGESTION. 



lates in the right side of the heart, and in the venous system gene- 
rally. Congestions on this account form a prominent feature in the 
pathology of asphyxia. From the observations of Dr. John Eeid, it 
appears that some obstruction also occurs to the passage of the blood 
through the systemic capillaries, as is proved by the increased pres- 
sure in the arteries, indicated by the hcemadynamometer. 

I stated that it remained for future observers to determine whether 
these obstructions are connected with contraction of the vessels (§ 120,) 
increased thickness or cohesion of the blood, or some other simply 
physical cause ; or whether they depend on peculiar vital attractions 
and repulsions exerted between the vessels and the blood, which are 
supposed by some physiologists to constitute an important element in 
the healthy, as well as in the morbid, phenomena of the capillary 
circulation. 1 

1 Whatever view may be held of the influence exerted by the properties of the blood 
in impeding its passage through the capillaries, the question is still left open whether 
the same power in any degree contributes to its motion. That the force of the heart, 
distributed by the arteries, is generally sufficient to carry on the circulation, is proved 
by several experiments of which some performed by Professor Sharpey, are the most con- 
vincing. A syringe, with a hsemadynamometer to show the amount of pressure used, 
was adapted to the thoracic portion of the aorta of a dog just killed, this vessel, having 
been previously tied immediately above the renal arteries, and the vena cava inferior 
having been opened at its exit from the diaphragm. Fresh bullock's blood, (deprived of 
its fibrin by whipping and straining, to prevent its coagulation,) was then injected with a 
pressure of three and a half inches of mercury, and it passed out of the vein in a free stream 
after having pervaded the double capillary system of the intestines and liver. When the pres- 
sure was increased to five inches of mercury, the blood spirted from the vein in a full 
jet. When the aorta was not tied above the renal arteries, but let free, the same pres- 
sure was sufficient to drive the blood through the extensive ramifications of the lower ex- 
tremities. On the same instrument being adapted to the pulmonary artery, it was found 
that a pressure of from one and a half to two inches of mercury was sufficient to propel 
the blood through the capillaries of the lungs, so that it flowed freely from the left au- 
ricle or pulmonary veins. 

The amount of force thus used is not greater than that which the hremadynamometer 
has shown the heart commonly to exert in propelling the blood during life, in the syste- 
mic and pulmonary circulation respectively; we thus obtain almost a demonstration, 
that the heart's power distributed by the arteries is generally sufficient to sustain the 
process of the circulation. 

The chief arguments for and against the existence of vital properties of attraction and 
repulsion exercised at sensible distances, have been well stated by Professor Allen Thom- 
son, in the article " Circulation," in the Cyclopaedia of Anatomy, to which I would par- 
ticularly refer the student. In addition to these, I would state that in many long and 
careful microscopic examinations of the circulation in the frog's web, variously modified 
by different experiments, I have never witnessed any movement of the blood corpuscles, 
which was not plainly referable to the action of the heart, or vessels. The share which 
the arteries have in regulating the flow of blood through the capillaries and veins is 
very evident. When the arteries increase in size, the flow becomes very rapid and ge- 
neral; when they diminish, the flow is tardy, and even ceases in some capillaries; and 
when the arteries contract, so as to permit no blood to pass through them, the blood 
which still fills the capillaries and veins, becomes quite stagnant, without a trace of spon- 
taneous movement. When motion begins again, it may always be traced to an artery, 
which first adniits a file of single corpuscles that come "few and far between," and in 
pulses; afterwards, as the artery enlarges, may rush on in a continuous rapid stream, 
supplying proportionate motion to the vessels beyond. These observations precisely 
correspond with others since made by Mr. Erichsen and numerous microscopic observers. 

Many of the instances of alleged vital motion in the blood, and in other organic mole- 
cules, are referable to mere physical causes. Similar movements may be seen, quite as 
animated in appearance, on mixing under the microscope two drops of saline solutions 
of different strength or nature; any insoluble powder placed in these drops may be ob- 
served to move, as it were, spontaneously, and the motion continues until the drops have 
entirely mingled each with the other. Still more lively motions are seen on adding any 



CAUSES — IN ASPHYXIA, ETC. 



217 



The researches of my friend Mr. Erichsen (Edin. Med. and Sur. 
Jmrn. No. 1G3) on Asphyxia, obtained results which seem in favour 
of the first of these alternatives, which had been previously suggested 

resinous tincture to water. The blood molecules are no doubt acted upon by the same 
physical influences that produce these phenomena. But the blood corpuscles are made 
to move also from another cause; they are not only carried by the current in which they 
float, but they are often changed in shape by it. Being vesicles, they swell or shrink 
through the influence of osmose, on any change occurring in the density of the liquid in 
which they are conveyed; and these changes affect their position and form, and their 
aggregation and separation, in a manner which readily suggests the idea of their possess- 
ing a power of spontaneous movement. 

Although it seems unwarrantable to admit any spontaneous motion in the blood-cor- 
puscles, or even any peculiarly vital motory power exercised over the blood by its vessels 
apart from muscular and tonic contractility, yet it is highly probable that chemical 
changes which take place in the capillary circulation may facilitate the motion of the 
blood ; and that when these changes are arrested or deranged, some obstruction or conges- 
tion may ensue. It is the opinion of many physiologists that there exists in the capillary 
blood-vessels a power supplementary to that of the heart and arteries, and that this power 
bears proportion to the activity of the changes taking place in the blood through all the 
tissues to which the vessels run; and that on a cessation of these changes the transit of 
blood is impeded. On this subject Dr. Carpenter writes thus: — 

"It appears from the preceding facts that the conditions under which the power in 
question uniformly operates, may be thus simply and definitely expressed. Whilst the 
injection of blood into the capillary vessels of every part of the system is due to the 
action of the heart, its rate of passage through those vessels is greatly modified by the 
degree of activity in the processes to which it should be normally subservient in them; — 
the current being rendered more rapid by an increase in their activity, and being stag- 
nated by their depression or total cessation. Or at any rate to use the more guarded 
language of Mr. Paget, 'we have facts enough to justify such an hypothesis, as that there 
may be some mutual relation between the blood and its vessels or the parts around them, 
which being natural, permits the most easy transit of the blood, but being disturbed, in- 
creases the hinderances to its passage.' A physical principle has been put forth by Pro- 
fessor Draper ('Treatise on the Forces which produce the organization of plants,' pp. 22 
— 41,) which seems quite adequate to explain these phenomena. It seems fully capable 
of proof that 'if two liquids communicate with one another in a capillary tube, or in a 
porous or parenchymatous structure, and have for that tube or structure different chemi- 
cal affinities, movements will ensue; that liquid which has the most energetic affinity will 
move with greatest velocity, and may even drive the other liquid before it.' Now arterial 
blood — containing oxygen, with which it is ready to part, and being prepared to receive 
in exchange the carbonic acid which the tissues set free — must obviously have a greater 
affinity for those tissues than venous blood, in which both these changes have already 
been effected. Consequently, upon mere physical principles, the arterial blood which 
enters the Sj'stemic capillaries on one side, must drive before it and expel on the other 
side of the network, the blood which has become venous whilst traversing it: but if the 
blood which enters the capillaries have no such affinity, no such motor power can be de- 
veloped. On the other hand, in the pulmonary capillaries the opposite affinities prevail. 
The venous blood and the air in the cells of the lungs have a mutual attraction, which is 
satisfied by the exchange of oxygen and carbonic acid that takes place through the walls 
of the capillaries, and when the blood has become arterialized, it no longer has any at- 
traction for the air. Upon the very same principle therefore, the venous blood will drive 
the arterial before it, whilst respiration is properly going on ; but if the supply of oxygen 
be interrupted, so that the blood is no longer aerated, no change in the affinities takes 
place whilst it traverses the capillary network ; the blood continuing venous still retains 
its need of a change, and its attraction for the walls of the capillaries; and its egress 
into the pulmonary veins is thus resisted rather than aided by the force generated in 
the lungs. The change in the condition of the blood in regard to the relative proportions 
of oxygen and carbonic acid, is the only one to which the pulmonary circulation is sub- 
servient; but in the systemic circulation, the changes are of a much more complex na- 
ture, every distinct organ attracts to itself the peculiar substances which it requires, as 
the materials of its own nutrition, and the nature of the affinities generated are conse- 
quently different in each case. But the same law may be considered to hold good in all 
instances. Thus the blood conveyed to the liver by the portal vein, contains the mate- 
rials at the expense of which the bile-secreting cells are developed; consequently the 
tissue of the liver, which is principally made up of these cells, possesses a certain de- 



218 



LOCAL HYPEREMIA — CONGESTION. 



(Med. Gaz., Sept. 1835 and 1838.) After having shown that analogy 
is not opposed to the fact that contraction is excited in the minute 
arteries by the passage of venous blood through them, Mr. Erichsen 
adds: — 

"But we may go a step farther, and prove that it (venous blood) 
actually possesses this power ; causing these vessels to contract dis- 
tinctly, as I have several times observed, on examining under the 
microscope, the mesentery of rabbits during and immediately after 
the process of asphyxia. This may be done without much difficulty, 
as the circulation of these animals, when quite young, continues for 
many minutes after the struggles of asphyxia have ceased. On 
asphyxiating a young rabbit, a portion of whose mesentery had been 
conveniently fixed under a powerful microscope, the following phe- 
nomena will be observed to ensue. For about a minute after the 
struggles of the animal have ceased, the circulation appears to be 
going on with its .usual rapidity; it then gradually becomes somewhat 
slower, the arteries contracting in size, containing less blood, and 
assuming a lighter and more tawny colour than before; whilst the 
veins become congested, and evidently fuller, assuming when viewed 
by transmitted light, a very beautiful crimson hue. As the circulation 
becomes more languid, the arteries continue contracting, and acquire 
a lighter colour, the diminution in their size, and the difference in 
the quantity of blood contained in them and in the veins, being most 
marked. The motion of the blood in the capillaries now becomes 
oscillatory, the whole mass of blood being at each impulse from the 
heart, slowly propelled forward, and then moving backwards. This 
to and fro motion continues for some time, and then ceases entirely. 
On restoring the heart's action by setting up artificial respiration, an 
impulse was evidently transmitted from the blood in the arteries to 
that in the capillaries, in a pulsatory and jerking manner, which was 
soon communicated to the veins, driving forward the whole mass of 
globules accumulated in them, and gradually becoming more equable 
and powerful until the circulation was completely restored. I have 
watched these phenomena most attentively in the mesenteries of 
young rabbits, and have never observed anything like spontaneous 
movements in the capillaries: the blood contained in which was inva- 
riably most clearly and distinctly influenced solely by the impulses 

gree of affinity or attraction for the blood containing these materials ; and this is di- 
minished so soon as they have been drawn from it into the cells around. Consequently 
the blood of the portal vein -will drive before it into the hepatic vein, the blood -which 
has traversed the capillaries of the portal system, and which has given up in doing so, 
the elements of bile to the solid tissues of the liver." (Principles of Human Physiology, 
1853, p. 500.) 

Now although I have always been opposed to the notion of peculiar "vital attractions 
and repulsions" as aiding the circulation, as being repugnant to the simplicity of nature, 
I am quite prepared to admit the influence of the chemico-physical agency here pointed 
out by Dr. Carpenter, and which seems to me to be identical with the "osmetic force" of 
Professor Graham, who traces this force to the chemical action exerted by the fluid on 
the substance of a porous or membranous system, and he considers it to obtain in the 
inj ection of the elementary cells of secreting organs. Further, the transit of fluids through 
membranes and capillary tubes in general must be amenable to the same laAv, which 
seems the more applicable to animal fluids and tissues, as they possess that weak saline 
impregnation with varying predominance of acid or alkaline reaction, which is most fa- 
vourable to the excitation of the osmotic force. 



CAUSES OF CAPILLARY OBSTRUCTION. 



219 



it received from that contained in the arteries. Nor have I ever 
been able to discover any obstruction in the vessels in consequence 
of the adhesion of colourless globules to the sides, — a phenomenon 
that I especially watched for, and which has by several been supposed 
to occur. The diminution in the diameter of the smaller arteries, and 
the proportionate difference between them and the neighbouring 
veius was most evident, and was such as could leave no doubt in my 
mind as to the important part that the contraction of these vessels 
plays in giving rise to an obstruction to the passage of the blood 
through them in asphyxia; in which I have no doubt that it is the 
principal, if not the sole agent. 7 ' 

298. These observations correspond perfectly with the many that 
I have myself made on the frog's web ; and, if accurate, they clearly 
prove that the motion of the blood in the capillaries is chiefly due to 
the force supplied through the arteries. It is fair to infer that a 
similar influence is also operative in the capillaries of the kings. It 
must, however, be admitted that pulmonary congestion resulting from 
the exclusion of air from the lungs is greater than can be accounted 
for by any contraction of the pulmonary arteries under such circum- 
stances. So also the re-admission of air certainly does remove the 
congestion and the attendant pressure in the veins more suddenly 
than might be expected to happen from the mere relaxation of tonic 
contraction. It is therefore highly probable that the movement is 
favoured by the change which the air produces in the blood, and that 
this auxiliary influence is no mysterious peculiarly vital power, but 
simply the operation of the osmotic force resulting from chemical 
change. This explanation has already been applied to the production 
and removal of congestions in the secreting organs (§ 296,) and may 
be extended to tissues generally, in which blood-changes are con- 
stantly proceeding. 

The instances of obstructed pulmonary circulation recorded in 
Mr. Blake's experiments, in which certain saline solutions (those of 
salts of soda, silver, &c.) caused death when injected into the veins 
by obstructing the passage of blood, without coagulating it or arresting 
the breath, admit of the same explanation. 

299. We have considered atony of the small vessels (§ 290) as one 
chief cause of congestion; it is so, not only by disposing them to 
yield, and to become distended by the accumulation of blood, but 
also by rendering them unfit to transmit the force of the current in 
its proper direction. Vessels which have lost their tone become 
inelastic and tortuous, and the very accumulation of blood in them, 
opposes an increasing obstacle to its passage through them. The 
physical principle to which I now refer is not generally understood, 
and I will therefore illustrate it by describing some experiments. 

300. To one of Read's enema syringes, a tube with two arms was 
adapted ; to one of these arms another brass tube two feet long was 
fitted, having several right angles in its course; to the other was tied 
a portion of rabbit's intestine, four feet long, and of a calibre (when 
distended with water) double that of the brass tube. The intestine 
was then placed in curves and coils, avoiding angles and crossings 
which might obliterate the canal. The discharging end of both tubes 



220 



LOCAL HYPEREMIA — CONGESTION. 



was raised to the same height, that of the intestine being kept open 
by a short tube of metal. The tubes were then both filled with fluid 
by successive strokes of the piston; and when they both began to 
discharge, the quantity that passed from each in a given number of 
strokes, was ascertained. Without entering upon details, it may be 
stated that the small metal tube discharged from two to five times 
the quantity that the larger or membranous tube did; the difference 
being greatest when the strokes of the piston were most forcible and 
sudclen, the intestine then, although much swelled at its syringe end 
at each stroke, conveying comparatively little water. The difference 
was further increased by raising the discharging ends higher; when 
both ends were raised to the height of eight or ten inches, the gut 
ceased to discharge at all, each stroke only moved the contained 
column of water so far that it could subside again without over- 
flowing. On increasing the force of the stroke, the part of the intes- 
tine nearest to the syringe, burst. 

This experiment was repeated with various modifications, of which 
I will mention one; a metal tube was used two feet eight inches long, 
and with a bore of three-eighths of an inch, and a portion of dog's 
intestine of the same length, but which, when distended, was of double 
the diameter. The orifice of the metal tube then passed three times 
more liquid than that of the intestine. 

301. These experiments show that flaccidity and increased length 
and size in a tube offer impediments to the passage of liquid through 
it; and although in the experiments, the difference between healthy 
and relaxed or congested vessels is exaggerated, yet by them enough, 
is really proved to warrant the conclusion that increased tortuosity 
and number of vessels in a congested part, greater mass of their con- 
tents, and atonic flaccidity of their coats, clo form additional obstacles 
to the passage of the blood moving in them, although the amount of 
the Qpposition varies according to the state of the circulation. 

302. These experiments serve to illustrate a principle that is not 
generally kept sufficiently in mind in the considerations of animal 
and general physics; the loss or neutralization of force, by mis-direc- 
tion. The blood-vessels in their healthy condition are so constituted 
as to make the most of the heart's propulsive power, and transfer it 
throughout their whole length: but when dilated, tortuous, flaccid, 
and otherwise altered, they misdirect and exhaust it: it is then, (like 
the force of the syringe in the experiment with the intestine,) partly 
expended in distending and dilating the nearer portion of the tubes, 
whilst a sufficiency of force does not remain for the onward propul- 
sion of the blood, which therefore stagnates and accumulates in the 
congested vessels. We shall have other occasions to revert to this 
principle, since by it may be explained many anomalies of unequal 
circulation. It is probably often concerned in keeping up congestion 
which has been for some time previously established by other causes; 
and it may sometimes be the means of perverting an increased flow 
through the arteries, which otherwise might sweep away the con- 
gested blood, — into that mixture of opposing forces, which exists in 
inflammation. The conversion of congestion into inflammation fre- 
quently occurs in circumstances that bear out these views. 



MISDIRECTION OF FORCE — SYMPTOMS. 



221 



THE SYMPTOMS AND EFFECTS OF CONGESTION. 

1. Effects in the congested part. 

303. When an arm is tied for venesection, the parts beyond the 
ligature become congested. At first the hand feels rather warmer 
than usual, and somewhat tender, in consequence of the distention of 
its vessels with warm blood, but it soon becomes numb, cold, and 
weak, showing that the arrest of circulation has lowered its vital pro- 
perties. In like manner, simple congestion generally impairs the 
vital powers of internal organs, although the unusual distention of 
their textures by the increased mass of blood, may cause partial ex- 
citement. Natural contractility and sensibility are lowered, whilst 
pain. (§ 126,) spasm (§ 114,) and morbid sympathies (§ 149,) are com- 
monly produced, but in a form that is much less distinct and constant 
than in inflammation or determination of blood. Thus congestion of 
the liver is sometimes accompanied by pain or tenderness; but some- 
times it is without either. Congestion of the stomach sometimes 
causes gastralgia, nausea, vomiting, and altered appetite; but these 
symptoms are often absent when the obvious amount of disease of the 
liver or heart, and the subsequent occurrence of haematemesis, leave 
no doubt that the stomach was congested. The same remark applies 
equally to the kidneys, the uterus, the brain, and other organs. We 
often see the tonsils and uvula congested and enlarged, without pain 
or soreness. Impaired nervous and muscular functions are more con- 
stant concomitants of congestion than pain, or symptoms of irritation 
of any kind. 

304. The natural secretions of congested parts are sometimes at 
first augmented, as in congestion of the conjunctiva and Schneiderian 
membrane from cold; but more generally they are diminished, as in 
bronchial congestion, (dry catarrh,) and congestion of the liver and 
kidneys. Yery commonly, congestion leads to an increased transu- 
dation from the whole of the distended capillaries, expressed in ef- 
fusions of the watery and saline part of the blood, which are more or 
less impregnated with albumen, and sometimes even with fibrin, as 
exemplified in the fluids of fluxes and dropsies. 

The means by which this effect of congestion is brought about seem 
to be chiefly of a physical nature. The portions of the vascular ap- 
paratus most immediately concerned in supplying the secreting struc- 
ture, appear to be the midmost of the capillaries, which are often so 
turned about and convoluted, that they receive the chief force of the 
current from the arteries. But when the vessels leading to these 
middle capillaries are congested, they too become tortuous, yielding, 
and loose, and much of the force derived from the heart is expended 
in effecting their dilatation, and is therefore intercepted from the ca- 
pillaries in immediate connexion with the secreting surface or cells; 1 

1 It may seem that this is taking too mechanical a view of the process of secretion ; 
hut be it remembered that I do not ascribe secretion wholly to mechanical agency, but 
only assert what is known to be a fact, that a due force of the capillary circulation is a 
condition favourable to the process. In formerly inspecting the beautifully injected pre- 
parations of the late Mr. Dalrymple and of Mr. Toynbee, I was particularly struck with 
the distribution of the capillaries of secreting surfaces, such as mucous and synovial mem- 



222 



LOCAL HYPEREMIA — CONGESTION. 



these are then in the condition of the distant end of the intestine in 
the experiment related above (§ 300,) not duly receiving the force of 
the current. The essential effect of congestion is thus to impair the 
natural process of secretion. 

305. But the distention of the congested capillaries sometimes leads 
to a general exhalation of the more watery part of their contents, 
which mingling with the natural secretion, renders it watery and 
sometimes albuminous. Thus congestion of the bronchi sometimes 
ends with bronchorrhoea. Congestion of the intestines causes diar- 
rhoea; congestion of the uterus, leucorrhcea; congestion of the kidneys, 
watery and sometimes albuminous urine; congestion of the lungs and 
pleura, hyclrothorax; of the heart, hydropericardium; and of the ab- 
domen, ascites. 

306. The element of congestion chiefly concerned in the production 
of these effusions, is extreme distention of the vessels. Such effects 
are less commonly found, therefore, in mere hypostatic or gravitative 
congestions (§ 291,) in which the distention is inconsiderable, but 
they commonly result from congestions brought about by venous ob- 
struction (§ 289,) especially when these occur suddenly, and whilst 
the vigour of the circulation is not impaired. Thus the congestions 
connected with diseased heart or liver, and produced by acute attacks 
or other additional causes of obstruction, especially in plethoric sub- 
jects, if not soon removed, are pretty sure to end with dropsy, flux, 
hemorrhage, or inflammation. The circumstances that determine 
which of these results shall ensue, will be considered when we come 
to treat of them specifically as elements of disease; but it may be 
mentioned that besides distention of the vessels, the condition of the 
blood has an important influence ; a watery state promotes the tran- 
sudation (§ 222,) whilst a highly albuminous and fibrinous state (§ 195) 
causes the blood to bear more pressure before its watery parts pass 
through the coats of the congested vessels. 

307. The same circumstances also affect the character of the effused 
fluid. Where the blood is poor, and the watery parts pass easily 
from the congested vessels, even without much distention, these con- 
tain but little albumen. But if the blood abounds in the protein com- 
pounds, and more pressure is required before much effusion takes 
place ; then, when the fluid is effused it often contains, not only albu- 
men in large proportion, but self-coagulating lymph also (§ 211.) 
Thus I have seen the fluid of the pleura and pericardium, in rapidly 
fatal obstructive mitral disease, coagulate spontaneously into a fibri- 
nous crassamentum, when removed from the dead body. The gela- 
tinous-looking masses of lymph often found in the peritoneal sac of 
the abdomen and pelvis in ascites from contracted liver, I have no 
hesitation in referring to the same origin. 1 

branes. These capillaries run pretty straight from the minute arteries, until they end in 
loops and ampullae on the surface, the returning vessels passing back as straightly. The 
physical effect of this provision is obviously to direct the chief force of the blood's 
movement on the terminal loops which supply the secreting surface. 

1 This is the true pathology of the "fibrinous dropsies" of Vogel and other German 
writers. Mr. Gulliver has found that even thin serous effusions, of low specific gravity, 
will sometimes form a coagulum under certain circumstances; as for example when 
two specimens are mixed together. 



EFFECTS ON STRUCTURE. 



223 



308. Fluxes arising from congestions of high tension exhibit an 
unusual amount of animal matter of an albuminous or mucous kind, 
as instanced in bronchorrhcea, mucous diarrhoea, and leucorrhcoa. I 
have been induced to suppose that the polypous concretions and pseudo- 
membranous films occasionally effused on mucous surfaces may result 
from long-continued congestion, with a highly fibrinous state of the 
blood (§ 195.) I have seen these evacuated from the air tubes, in 
one case, and in several others from the intestines, from time to time, 
for months, and even years, without the existence of symptoms of in- 
flammation, but under circumstances which render it probable that 
congestion was present. Extensive disease of the heart existed in 
the former case, and disease of the liver, or amenorrhoea, in the latter. 

309. Several years ago I referred albuminous urine (§ 249) to con- 
gestion of the kidney; and this view has been subsequently confirmed 
by some experiments of Dr. Gr. Robinson. The following were the 
considerations that led me to my conclusion: — 1. The urine often be- 
comes albuminous during great embarrassment of the circulation in 
cases of organic disease of the heart or lungs (§ 289,) when the kid- 
neys are otherwise healthy. 2.1 have in many instances observed 
temporary albuminuria during the cold stage of ague, and in the con- 
gestive stage of eruptive fevers. 3. In granular degeneration of the 
kidney, the amount of albumen in the urine is augmented by circum- 
stances that cause congestion of the kidney, and is reduced by reme- 
dies suited to remove the condition. 4. The most common form of 
Bright's disease of the kidney presents, in its earliest stage, the ap- 
pearance of a highly congested structure, and it is excited by causes 
calculated to produce congestion, such as frequent irritation of the 
kidneys by stimulating liquors — leading to the congestion of ex- 
hausted tone (§ 294;) continued exposure to cold, especially after the 
kidneys have been thus excited — leading to the congestion of intro- 
pulsion (§ 292 :) scarlatina probably produces the same result by first 
irritating the kidneys, then inducing congestion in them. 5. Albu- 
men is most abundant in the urine in the congestive (first) stage of 
Bright's disease — the vessels becoming more or less obstructed in the 
progress of the disorder by the deposit of fibrin with granular cells 
in the tubules, and in some instances, around them, which deposit at 
the same time perpetuates some degree of congestion, whilst the pro- 
per secreting structure is in a degree displaced. 1 

1 The secreting structure is partly diminished in another way also. The granular 
deposit presses not only on the blood-vessels, but on the uriniferous tubuli too; and 
wherever it totally obstructs them, their office ceases. These tubuli becoming distended, 
form the serous cysts so commonly found in granular kidneys, and sometimes in those 
which are not granular. The cysts contain serum, or a jelly-like matter with little or 
no urine ; and this fact has been urged against the view that they are dilated uriniferous 
tubes. The removal of the objection, however, is not difficult. The secreting function 
of the kidney lies in nucleated cells lining the tubuli, (Bowman;) growing, filling, and 
bursting, as these cells do, by imbibition from adjoining vessels, this process, which is 
that of secretion, must be stopped when the cells are themselves pressed on by an accu- 
mulation of their own secretion, which cannot escape; but a serous exudation from the 
blood-vessels still goes on, displacing by osmosis the urine, and at last distending the duct 
into a cyst. The same explanation applies to the formation of the serous cysts of the 
liver. This view also accounts for retention of urine or bile leading to the suppression 
of the secreting power of the kidneys or liver. 

The above note appeared in the first edition, but it expresses what still appears to me 



224 LOCAL HYPEREMIA — CONGESTION. 

310. From what has just been stated it may be inferred that con- 
gestion, if long continued, may affect both the nutrition and structure 
of textures. It generally tends to cause abnormally increased deposit 
in them, constituting a variety of hypertrophy , or overflow of plastic 
matter. Thus, where diseases of the heart cause congestion, there 
is an increase in the weight of the viscera generally, and more par- 
ticularly of the lungs and liver. (Clendinning.) The enlargements 
of the liver and the spleen induced by long continued attacks of in- 
termittent fever (called ague-cake) may probably be referred to the 
congestion which this disease unquestionably induces (§ 293.) I have 
known a similar enlargement of these organs to ensue after long 
continued exposure to cold and damp (§ 77, 292.) 

311. But the hypertrophy that results from congestion is probably 
not of a uniform kind, comprising equal enlargement of all the tex- 
tures; arising as it does from an effusion of lymph out of the most 
congested vessels, it is an intervascular deposit — at first mottling and 
exaggerating the natural appearance of the structure, as seen in the 
nutmeg liver and in the early soft stage of granular degeneration of 
the kidney — afterwards contracting and compressing the structure, 
and ultimately causing its condensation and atrophy, whilst the new 
deposit itself forms a granular or nodulated texture of low vitality 
(§ 211.) 

312. Such I believe to be the nature and origin of some varieties 
of cirrhosis of the liver, and of granular degeneration of the kidney. 
The diversities which these structural diseases present may often be 
traced to their degree of advancement, or to the extent to which they 
involve the textures; and an argument in favour of their having their 
origin in congestion may be found in the fact that they are commonly 
seen to be most advanced and extensive in the most dependent parts 
of the organs; as the lower margins of the liver, where of course 
congestion is promoted by gravity (§ 290.) It is however highly pro- 
bable, that these plastic products of congestion are also, in some 
cases, more or less developed, and still farther modified, by determi- 
nation of blood or inflammation, and by peculiar composition of the 
blood itself. Thus in some instances the deposit exhibits a fibrous 
or closely compacted granular character, and is firmly adherent to the 
investing membrane, which is more the character of an inflammatory 
product. In others the deposit is loosely granular, or in irregular 
cells, often with a predominance of fat globules in it, and with little 
cohesion : this resembles the degenerative condition of the plastic 
effusions found in scrofulous or cachectic states. 

Long-continued congestion in the lungs may cause hypertrophy of 
the intervesicular and interlobular texture, and in some cases, even 
partial consolidation of the vesicular structure itself. Such changes 
are frequently met with in connexion with long-standing disease of 
the heart, and occur most commonly in the posterior parts of the 
lungs, and near their roots, which are the most vascular parts. In 

the true view of the origin of cysts in the kidney, and it corresponds with an opinion 
subsequently advanced by Dr. George Johnson, in a paper read to the Medico-Chirurgical 
Society. At the same meeting a communication from Mr. Simon alluded to the cysts as 
being enlarged epithelial cells, developed in conseqtience of the obliteration of many of 
the tubes. 



EFFECTS ON THE SYSTEM. 



225 



the membranes of the brain, and in the capsules of the heart, liver, 
and spleen, opaque thickening is often seen along the course of the 
blood-vessels, especially of the veins; apparently the result of the 
overflow of nutritive matter from these vessels. 

2. Effects of local Congestion on the system. 
When a congestion is extensive, it has constitutional as well as 
local effects. In proportion as blood accumulates in excess in a part, 
it leaves the rest of the body with less than its proper share, and so 
causes the limbs and surface generally to give various indications of 
weak circulation and want of blood. Thus with considerable con- 
gestion of the liver, lungs, or brain, the surface is generally pallid 
and chilly, the pulse is weak and small, the extremities are cold, 
there is a peculiar feeling of languor or weariness, and all the vital 
functions are indifferently performed. A similar state of the system 
may be produced artificially, by applying a tight bandage around both 
thighs at once, or even both arms in a weak person: the limbs beyond 
the ligature become congested (§ 289,) and a deficiency of blood is 
left in the rest of the body. The extreme of this condition is seen in 
the cold fit of an ague, in which extensive internal congestions are 
essential pathological states (§ 293.) In this, as with other extensive 
congestions, more especially if suddenly induced (as by cold, § 294.) 
reaction often ensues (§ 16,) causing quickened pulse and circulation, 
hot skin, and other phenomena of fever. Where this reaction is vi- 
gorous, it may fulfil the object for which it is designed by Nature, by 
sweeping back the congested blood into the circulation, and so re- 
storing the balance. Where, however, the reaction is weak, it fails 
to remove the congestion, but constitutes instead a low feverish ex- 
citement, often remittent in type, accompanied by depraved state of 
the functions, foul tongue, impaired excretions, and restless nights, 
and this state of things may continue for an indefinite period, until a 
critical evacuation by sweat, urine, or diarrhoea (§ 171) terminates it, 
and with it the congestion that had led to the disorder. In other 
cases, there is no appearance of reaction; but the congestion, if ex- 
tensive, is not without its injurious constitutional effects: the stagnant 
blood, unpurified and unrenovated, becomes gradually injured in its 
composition; and not only unfit for farther use in the economy, but 
a source of contamination to the rest of the nutritive liquid (§ 191,) 
and a cause of cachexia in the system at large. Extreme results of 
this kind are presented in the slow operation of malaria upon persons 
who are continually exposed to the noxious influence (§ 85,) and in 
the low apyrexial congestions which precede typhoid pneumonia: but 
slighter examples are more commonly and frequently offered in pa- 
tients whose general health has suffered from habitual congestion, 
and in whom the loaded and vitiated excretions, which, even without 
fever, continue to be thrown off, afford evidence of a process of decay 
in the animal fluids, — the necessary consequence of imperfect purifi- 
cation. 

REMEDIES FOR CONGESTION. 

313. The most important measures to be adopted for the removal 
of congestion are such as are addressed to the causes of the disorder. 
15 



226 LOCAL HYPEREMIA— CONGESTION". 

Thus the loosening of a ligature, or the reduction of a tumour, com- 
pressing a vein; the moderating the inordinate and inefficient action 
of a diseased heart; the restoration of the secretion of the liver (§ 172,) 
— all severally tend to diminish congestions resulting from these 
different causes of venous obstruction. 

314. So, also, in the treatment of the congestion of atony or weak- 
ness of the capillaries, it is most important that the circumstances 
which have caused the condition should be removed. In many cases 
over-distention from gravitation may be at the bottom of the mischief 
(§ 296;) then change of posture gives relief. In congestive fevers, 
and other states of long-continued weakness, it is on this account 
beneficial to change from time to time the position of the patient, 
from supine to prone, or to lying on either side. Where there is 
congestion of the head, this part should be supported high. The re- 
cumbent posture gives much relief in congested hemorrhoidal or 
uterine vessels; and it may be seen to reduce the swelling of varicose 
limbs. 

Pressure may sometimes be made a remedy for congestion, by sup- 
porting the weak vessels and promoting their contraction. This 
forms a chief part of the useful operation of bandages, adhesive plas- 
ters, and even of poultices, in various external congestions. Pres- 
sure probably might be more extensively applied in these cases, and 
even also in others where there are internal congestions, in the modes 
suggested by Dr. Arnott, through the instrumentality of mercury, or 
by the soft slack vulcanized India-rubber air or water pad. 

Friction is a modification of pressure especially suitable to some 
forms of congestion, being calculated to communicate the motion that 
is defective, as well as to support the weak vessels. It is obviously 
useful in external congestions caused by cold; and sometimes also in 
visceral congestions, as those of the liver and abdomen generally. 
Exercise operates somewhat in the same way. 

315. Another class of remedies for congestion comprehends such 
influences as promote the contraction of the dilated vessels by aug- 
menting their contractility or tone (§ 124.) It is in this way that 
astringents and cold operate; as when solutions of alum, sulphates of 
zinc or copper, acetates of zinc or lead, and infusion or decoction of 
oak bark, catechu, kino, and nutgalls, are applied in congestions of 
the conjunctiva, throat, rectum, and vagina. The most obvious por- 
tion of the action of bark, quinine, and arsenic in the cure of 
ague, depends upon their reducing the great visceral congestions, 
which form the most remarkable, and perhaps the most important pa- 
thological element of these disorders. 

316. The utility of astringents in congestion is limited by the fact, 
(demonstrable under the microscope,) that they commonly contract 
the arteries more in proportion, than the capillaries and veins which 
are the distended parts in this state. Hence their application may 
chance still farther to arrest the motion of the blood, and so increase 
the congestion. A reaction, however, sometimes occurs, which con- 
verts the operation of the astringent into that of the stimulant, which 
is another of the remedial powers adapted for the relief of congestion. 
The same remark applies also to cold; and with even more certainty 



TREATMENT — ASTRINGENTS, TONICS, STIMULANTS. 



227 



and force, inasmuch as this agent causes a physical obstruction to the 
flow of blood, in another manner formerly described (§ 296.) 

Stimulants are sometimes remarkably effectual in removing con- 
gestions. Thus a diluted spirit lotion applied to a congested con- 
junctiva, a capsicum gargle to a congested throat, a stimulating 
wash or ointment to a purple sore or surface, often prove signally re- 
medial. Other congestions may be dispelled by exciting the general 
circulation; a draught of stimulant medicine, or of any hot liquid, 
often relieves the pulmonary congestion which has induced a fit of 
asthma; a congestive headache is sometimes mitigated by similar 
means. Well regulated exercise tends to disperse congestion in va- 
rious parts. Agents, which specifically excite particular organs or 
parts (§ 173) are often useful in removing congestions from them. 
Thus mercury is, to a certain extent, a remedy for a congested liver ; 
some diuretics, such as digitalis and cantharides, are remedies for 
congested kidneys; squill, benzoin, ammoniacum, and other expecto- 
rants, for bronchial congestion. 

317. The influence of stimulants on congestion may be directly ob- 
served by the microscope. When a solution of capsicum is applied 
to the web of a frog's foot, congested from previous irritation, it 
causes an enlargement of the arteries, and an increased flow of blood 
to and through the congested vessels. This flow restores motion 
where it was deficient, sweeps away the accumulated blood, and, in 
some instances, causes the vessels to contract afterwards to their na- 
tural size; so that then the congestion is completely removed and the 
cure complete. In other instances, however, the stimulation fails to 
clear the congested vessels; the enlarged arteries pour more blood 
into them; and if this does not overcome the obstruction it increases 
the hyperemia, and, as we shall afterwards see, may even convert it 
into inflammation. Thus it appears that stimulants as well as astrin- 
gents, although occasionally proving suitable and effectual remedies 
for congestion, sometimes tend to increase it; this latter they are 
most likely to do, when the congestion is extensive, or of long con- 
tinuance, or when its causes are still in operation. 

318. Under such circumstances, congestion is best relieved by the 
adoption of another course; the employment namely of depletion, and 
various evacuants. Blood-letting, by puncture or incision of the con- 
gested parts, enables the distended vessels to unload themselves, and 
in this way they may recover their natural size ; the utility of this 
expedient is proved when scarifications of congested conjunctivae and 
tonsils are made, and when leeches are applied to a congested os 
uteri. The blood is, however, more usually drawn from the vicinity 
of the congested part, as when cupping, or leeches on the chest or 
side, are employed for congested lungs or liver; 1 or over the sacrum 
for congested uterus; or when the anus is leeched for congested in- 
testines. Or, without actually shedding the blood, it may be drawn 

1 It is singular how quickly congestions may be reduced by these means. I have 
known a congested liver, which reached from the umbilicus to the fourth right rib, (as 
traced by percussion,) reduced in twelve hours to its normal dimensions by cupping and 
free purging. Piorry describes a still more speedy reduction of the liver in ague by the 
influence of the sulphate of quinine. 



228 



LOCAL HYPEREMIA — CONGESTION. 



away from congested parts by derivation; that is, by agents which 
cause determination of blood or congestion in other parts; as dry 
cupping, mustard poultices, and other stimulating applications to the 
surface, and by purgatives and other evacuants from the interior. A 
still more powerful agency of the class of derivants is the removal of 
atmospheric pressure from a limb by enclosing it in an air-tight 
vessel, and thus partially exhausting the air. This plan was invented 
by Dr. Arnott, and has been lately used by Sir James Murray and 
several French practitioners. 

These measures, then, act by inducing determination of blood, or 
even inflammation in another part, and so drawing away blood from 
the congested structure. Other means however may be employed, 
which prevent or remove congestion by damming up the blood in other 
parts, and so induce a counter-congestion. It has long been the prac- 
tice of some to attempt to stop a n't of ague by applying a tourniquet 
to the thigh; and Dr. Buckler of Baltimore, led by a popular pro- 
ceeding of a similar kind, has called the attention of the profession to 
the general utility of the remedial measure which he terms hcemostase; 
this consists in the temporary application of tight ligatures to one or 
more limbs, which are thereby congested so much, that there is not 
blood enough left in the circulation to supply the originally congested 
vessels, so that when these are relieved of the pressure, they contract 
and expel the accumulated blood. I have employed this plan in se- 
veral cases in which temporary congestions were produced in the 
lungs and liver, and sometimes with a very marked effect; but it has 
little influence on congestions which have long been formed, and acts 
chiefly on the distribution of blood in the larger blood-vessels. 

319. The operation of several of the foregoing agents, employed in 
combination or in succession, is generally more effectual than that of 
cither used alone, in the cure of congestions. Thus congestion of the 
liver may resist the action of mercury, and may even be aggravated 
by it (§ 294,) until the vascular distention has been partially reduced 
by local blood-letting or derivation; then the mercury increases the 
secretion, and relieves the remaining congestion. Congestion of the 
kidneys is augmented, rather than diminished, by the employment of 
diuretics, which fail when used in the first instance to increase the 
secretion of urine, and sometimes only render it more albuminous 
(§ 304.) But after some relief has been secured by cupping the loins, 
and the administration of hydragogue purgatives and diaphoretics, 
then certain diuretics, particularly digitalis and cantharides, cause a 
freer flow of urine less loaded with albumen. This point might be 
farther exemplified ; but it is unnecessary to multiply instances. 

320. The cause of congestion being, in many instances, atony of 
the vessels (§ 290,) the mischief may often be counteracted by cir- 
cumstances which augment the tone of the vessels, locally or gene- 
rally. Thus cold, astringent, or, occasionally, stimulant applications, 
brace the fibres and invigorate the circulation in a part (§ 124,) and 
so render it less liable to congestion from disease; general tonic 
measures operate in a similar way on the whole system. The efficacy 
of bark and arsenic in preventing, as well as in removing the internal 
congestions of ague, probably depends on the power of these medi- 



EXAMPLES, NATURAL AND MORBID. 



229 



cines to augment the tone of the vessels of the affected parts (§ 315,) 
so that they no longer yield to the distensive accumulation of blood 
within them. A similar virtue seems to be possessed, in some degree, 
by iodine and bromine and their preparations, especially the iodide 
and bromide of potassium; under their use the disposition to local 
congestions is diminished, and such as are formed are sometimes dis- 
persed, as is exemplified by their external use in lepra and other con- 
gestions of the skin, and by that of iodide of potassium in congestive 
headache. Mineral acids and other tonics have a like effect in cases 
of general weakness. The treatment best calculated to remove the 
results of congestion will be most appropriately considered under the 
heads, Hemorrhage, Flux, Dropsy and Inflammation. 



SECTION V. 
LOCAL HYPEREMIA— EXCESS OF BLOOD IN A PART. 
II. WITH MOTION INCREASED — DETERMINATION OF BLOOD. 

321. Numerous examples of this kind of active hyperemia are pre- 
sented in health as well as in disease. The face and neck in blushing, 
the uterus and breasts at the periods of gestation and lactation, the 
gums during the process of dentition, the antlers of the stag at the 
season of their development, are instances of local determination of 
blood occurring in health. The increased number and size of the 
blood-vessels, in these cases, manifested in the vascular redness, show 
the increased quantity of blood in the part; and the stronger pulsa- 
tion of the arteries leading to the part indicates the augmented motion 
of that blood (§ 274.) 

322. In disease we meet with many examples. Determination to 
the head is one that is familiarly known ; and it well displays one of 
the characteristics of the condition in the enlargement and throbbing 
of the carotid arteries. I have witnessed this phenomenon in a great 
variety of cases. One patient was subject to attacks of determination 
of blood, which caused him so much suffering and loss of moral con- 
trol, that he cut his throat to destroy his life. Whilst recovering 
from the wound, attacks sometimes came on; first with beating of the 
carotids, then with flushing of the face and head, suffusion of the eyes, 
and sensations of distraction in the head. In the slighter attacks, 
these symptoms would all pass away in a minute or two. I have, in 
several cases, observed the same symptoms usher in the paroxysms of 
mania. Fits of epilepsy and convulsive hysteria are immediately pre- 
ceded by throbbing of the carotids, which shows that determination 
of blood is the proximate cause of the paroxysm. Drs. Darwin and 
Parry relate cases in which convulsive fits were prevented by pressure 
on one of the carotids; and I have practised this expedient with suc- 
cess in several instances. Many of the epileptic patients whom I 
have questioned have stated that the fit is always preceded by palpi- 
tation, which, for reasons before explained (§ 266,) is very apt to de- 



230 



LOCAL HYPEREMIA- 



. — DETERMINATION OF BLOOD. 



termiue blood to the head. But without the patient being conscious 
of palpitation, there may be determination of blood to the head; and 
I have found this to be so commonly present, in various kinds of dis- 
order which affect the nervous centres, that I believe it to be the 
common immediate cause of sudden paroxysms in such. Infantile" 
and puerperal convulsions are probably to be included amongst the 
cases referred to in this remark, although they may be connected with 
very different conditions of the vascular system in the matter of ful- 
ness, and are to a great extent dependent upon an imperfectly puri- 
fied condition of the blood itself (§ 249.) 

323. But the most common cases of determination of blood are 
those caused by the application of stimuli. Thus heat causes a flow 
of blood to the surface; snuff, to the nose and eyes; spices in the 
mouth, to the salivary glands : food in the stomach, to its secernent ves- 
sels; purgatives, to the vessels of the intestines, and those of glands 
connected with them: diuretics to those of the kidneys, &c, &c. In 
fact, the operation of most medicines is connected with their causing 
an increased flow of blood to particular organs or surfaces; and there 
are few diseases in which local determination of blood does not take 
place. We shall find hereafter that it occurs in inflammation as a 
part of that complex process; but Dr. Parry was wrong in supposing 
that inflammation consists in determination of blood alone. 

324. Now, what is the physical cause of determination of blood? 
In some cases, increased action of the heart (§ 112) may propel the 
blood with unusual force and in unusual quantity to the arteries in 
its immediate vicinity: more particularly when there is little blood 
in the system, and that little accumulates in and near the heart, as in 
cases of anaemia (§ 266,) or in the commencing reaction consequent 
upon great congestion of internal organs, as in the beginning of the 
hot stage of fevers: determination of blood to the lungs and bronchi, 
to the neck, and to the head, is a common result of inordinate action 
of the heart. But in many of the examples above cited (§ 323, 324.) 
local determination takes place without any increase of the heart's 
action, and must therefore be due to another cause. 

Is this determination of blood then caused by increased action of 
the arteries? The only active property which we know these vessels 
to possess is that of slow or tonic contraction (§ 120 :) such contraction 
of arteries, leading to any part, would diminish instead of increasing 
the motion and quantity of blood proceeding to it (§ 294.) We have 
hence warrant for the conclusion that simple determination is not 
caused by exaltation of the natural powers of the arterial structures. 

325. On the other hand, direct observation, as well as reason, point 
out that determination of blood is caused by enlargement of the arte- 
ries ; this enlargement is the effect of increased pressure acting from 
behind on a tube which has lost some of its contractile power (§ 120.) 
The tonicity of the arteries makes them naturally resist the distend- 
ing influence of the mass of blood pumped into them by the heart; 
but when this tonicity is impaired in any artery, the contractile power 
of the branch or branches nearer to the heart still goes on forcing 
blood into it; it however, being weakened, yields to this force, instead 
of resisting in turn and pushing on the blood, and so gets dilated, and 



CAUSES — EXPERIMENTAL ILLUSTRATIONS. 



231 



becomes an enlarged channel for the transmission of more blood and 
more force to the vessels farther on (§ 323.) Hence when an artery 
is thus enlarged, the capillaries and veins to which it leads also get 
dilated, and share the increase of blood and motion (§ 298, note.) 
The proof of the enlargement and distention of arteries running to 
an inflamed or irritated part is offered in the increased and harder 
pulse felt in them; the coats of the vessels being so much more 
stretched, and at the same time rendered less elastic, the pulse is no 
longer softened by the usual spring. 

When the web of a frog's foot is gently irritated by an aromatic 
water, the arteries may be seen through the microscope to become 
enlarged, and to supply a fuller and more impulsive flow of blood to 
the capillaries and veins, which then all become enlarged too; the 
whole vascular plexus, including vessels which before scarcely ad- 
mitted red corpuscles, then becomes the seat of a largely increased, 
current. This is determination of blood. 

326. As these phenomena have not been distinctly described by 
observers, apart from the effects of over-irritation, which leads to ob- 
struction and inflammation, I will state shortly the results of many 
observations I have been able to make, on the influence of moderate 
stimuli applied to the web of a frog's foot. These observations were 
made in the summer of 1841, and some of them are mentioned in my 
Gulstonian Lectures, published in the Medical Gazette of July, 1841, 

The arteries may be distinguished from the veins in the web of the 
frog's foot, not only by the direction of their current and its greater 
rapidity and transparency, but also by the presence of a series of lines 
running along their course ; these lines mark the size to which they 
have been distended at some previous time. (See A, fig. 1.) These 
linear channeling^ are most distinct, and they are also more remote 
from the artery at its angles or bifurcations. They are to be seen at 
some points along the veins, but much less plainly. Now these lines 
are in themselves proofs of the varying distention of the arteries, 
and they also furnish the means of measuring the amount of the varia- 
tions. 

When a weak infusion of capsicum is applied by a camel's-hair 
pencil to the web, there is a momentary retardation of the current in 
the veins, and the artery distinctly shrinks in size. But in a few 
seconds the reverse takes place ; the artery swells to beyond its for- 
mer size, and reaches the outmost line of its channel; the flow of blood 
through it becomes too rapid to be distinguished, and all the capilla- 
ries present a scene of busy motion: in some the particles pass in 
numbers and speed greater than the eye can follow ; in others that 
were before invisible, single files may be noticed forcing their way 
in more deliberate, but continuous motion; in the veins the movement 
is again more rapid. This motion however soon begins to flag, and 
becomes remittent or oscillatory in some capillaries; and it may then 
be seen that the arteries have already begun to shrink in size, and the 
channelled lines, which had been effaced, to re-appear. Sometimes , 
in shrinking, the artery assumes for a time a more tortuous shape than 
before, (as A, in fig. 2;) so that its walls cease to be parallel with the 
outlying lines; this seems to show that the vessel contracts in diameter 



232 LOCAL HYPEREMIA — DETERMINATION OF BLOOD. 

before its length is proportionally reduced. The contraction of the 
artery, and consequent reduction of the quantity and movement of the 

Fig. 1. Fig. 2. 




blood in the vascular plexus, was promoted by repeated applications 
of cold water (§ 124.) which in some instances stopped the motion of 
the blood altogether, by diminishing the artery to so small a size, that 
no blood corpuscles entered it. A weak solution of acetate of lead 
produced this effect in a more decided degree. 

The determination of blood excited by the means described above 
produces an increased redness that is quite perceptible to the naked 
eye; but it is less intense and of lighter hue than the redness of in- 
flammation or congestion. 

Several years subsequently to my experiments, Mr. Paget observed 
that the small arteries of the web of a frog's foot contract after being 
slightly irritated by the scratching of the point of a needle over them, 
and presently afterwards enlarge to beyond their original size (Lec- 
tures on Inflammation, Med. Gaz., June, 1850.) Mr. Wharton Jones 
noticed that a great enlargement with increased current, preceded by 
little or no constriction, followed the application of wine, of spirit, of 
opium, of a strong solution of salt, and of a weak solution of sulphate 
of copper. A strong solution of sulphate of copper, on the other hand, 
produced dilatation of the vessels, followed slowly by permanent con- 
striction (Prize Essay on Inflammation, Guy's Hospital Reports, 1850.) 

It has been objected that I assume enlargement of vessels to be 
the cause both of increased motion (in determination) and diminished 
motion (in congestion.) which seems contradictory; but if my oppo- 



CAUSES AND NATURE. 



233 



nents fully consider all my explanation of these conditions, they will 
cease to hold that there is contradiction anywhere. In determination 
the vessels enlarged are the arteries, which being near to the source 
of motion and highly charged with its propulsive power, give vent to 
the stream as a reservoir under high pressure would : whereas in 
atonic congestion the vessels enlarged are the veins and capillaries, 
which are remote from the source of motion, and receive their impulse 
only through the arteries, which are not enlarged, and they may be 
even contracted (§ 294 ;) thus the accumulated blood becomes com- 
paratively stagnant. There is nothing contradictory in these appli- 
cations of simple hydraulic principles : they are indeed farther illus- 
trated by the fact, that those parts are most liable to determination 
of blood which are nearest to the source of power; thus the head, 
face, and neck, present this phenomenon much more frequently than 
the structures of the lower extremities. 

327. There appears, then, to be no difficulty in tracing local deter- 
mination of blood to an efficient physical cause, enlargement of the 
arteries leading to the affected part; and if it is not equally easy to 
give a physiological explanation of the cause of this enlargement, it 
is only because the intimate nature of the tonic contractility of arteries 
has not yet been sufficiently studied. The terms " active dilatation 77 
(Hunter) and " vital turgescence 77 (Kaltenbrunner) have been ap- 
plied to the condition in question; but all that is known of animal 
physics is opposed to the possibility of there being a power of active 
dilatation in the arteries. It is quite true that in many instances of de- 
termination of blood, the exciting cause seems to operate directly, in 
stimulating the functions of the cells or tissues in connexion with the 
capillaries, rather than to be expended immediately on the arteries; 
but the arterial enlargement must follow before there is determina- 
tion of blood; and assuredly there are cases of determination of blood 
where there is no previous capillary excitement. 

The essential physiological cause of the arterial enlargement seems 
to be a weakening or reduction of the tone (§ 123) of the vessel, so 
that it becomes passively distended by the normal vis a tergo sent 
from the heart. In some cases, it might be supposed that this weak- 
ness was the result of exhaustion from stimulation (§ 116;) and it has 
been stated above that a momentary contraction of the artery does 
precede its dilatation. But the amount of dilatation is out of all pro- 
portion to the previous contraction; and, in some cases, as in blushing, 
in the results that follow the application of heat, and in the natural 
growth of parts, there is no sign of any previous contraction having 
occurred. 

328. Dr. Billing ingeniously conceives that, by stimulating the 
nerves, the nervous influence is drawn away from the vessels; and 
that their contractility, derived from this influence, is thus impaired. 
There can be little doubt that the nerves — especially the sympathetic 
(§ 152) — are sometimes concerned in causing determination of blood; 
and it is not improbable that they do so by reducing the contractility 
of particular arteries, just as strong moral emotions, acting through 
the nerves, paralyze the sphincters and muscles of voluntary motion 
(§ 144, 154.) Yalentin and others have observed distinct contraction 



234 



LOCAL HYPEREMIA- 



. — DETERMINATION OF BLOOD. 



of the aorta on irritating the sympathetic nerve or the roots of the 
cervical nerves. Probably this contraction is followed by enlarge- 
ment and consequent determination of blood. The recent experi- 
ments of.M. Bernard clearly bear on this point. He found that divi- 
sion of the sympathetic nerve in the neck of the rabbit was immedi- 
ately followed by enlargement of the blood-vessels of the eye and ear 
of the same side, with throbbing, and increase of sensibility and tem- 
perature, — symptoms, in fact, of determination of blood; and this 
condition continued for several days (G-az. Me'dicale, Jan., 1854.) The 
injury to the sympathetic seems, therefore, to impair the tonicity of 
the vessels, and thus to cause their dilatation with increased current 
of blood through them. Mr. Wharton Jones has also found dilatation 
of the arteries and increased current of blood through the leg of a 
frog, after section of the ischiatic nerve when it had connexion only 
with the sympathetic system. But the intimate nature of tonicity, the 
laws which it obeys, and its relation to the nervous influence, still re- 
quire farther investigation. 

329. We can readily understand the final cause or purpose of de- 
termination of blood. "Ubi stimulus, ibi fiuxus." The increased 
flow is intended to preserve the well-being and to support the func- 
tion of the part. If any accidental influence threaten its well-being 
or excite its function, more blood is wanted: the arteries therefore 
dilate, to supply more, and to allow it to arrive with greater force, 
and so the circulation through the part is augmented. The result is, 
if in moderation, to increase the redness, warmth, sensibility, secre- 
tion, nutrition, and other functions; and if in excess, to disorder and 
alter them. 

330. We have hitherto considered local determination of blood as 
resulting from causes which directly affect that part of the vascular 
system in which the determination takes place. In not a few cases, 
however, the same result arises from causes acting on distant parts 
of the vascular system. Thus external cold causes internal conges- 
tions by intropulsion (§ 292,) and so too it may occasion internal de- 
terminations of blood. By constricting the vessels of the surface and 
extremities, it directs the force, as well as the chief quantity of the 
circulating fluid on internal parts that are- beyond its constringing in- 
fluence. Thus in many persons, cold applied to the surface and ex- 
tremities, causes palpitation, dyspnoea, pain in the chest, throbbing, 
pain and heat in the head, gastralgia, colic, and fluxes of various kinds. 
It is obvious that in such cases the force of the heart is expended 
chiefly on the arteries of the internal organs, which thence become 
dilated, and are the seat of determination of blood; whilst those of 
the surface and extremities are contracted and bloodless. The com- 
mencement of reaction from the cold stage of a fever is commonly 
marked by determination of blood to the head and other parts in like 
intimate relation with the centre of the circulation, which hence get 
excited, and suffer more or less pain and disorder. 

The subjects in whom cold causes internal determinations of blood, 
are chiefly those who are endowed with much irritability of heart 
(§ 113,) and who have but little blood (§ 261.) The same persons 
likewise are liable to a flush of blood to the face and head, and to 



SYMPTOMS AND EFFECTS. 



235 



coldness of the feet, when they go into a warm room. By heating the 
head, the feet are made cold; if, on the other hand, the feet are 
warmed, the head is cooled. 

331. Attacks of local determination of blood induced by other causes 
are often accompanied by shivering fits, palliclity of the surface, cold- 
ness of the extremities, and defective secretions, particularly in per- 
sons of weak circulation. When an unusual quantity and force of 
blood are determined to one part, there must be less of both in other 
parts, which therefore suffer from the deficient supply. This connects 
itself with an important therapeutic principle, to be noticed hereafter. 

332. As we find determination of blood to be chiefly produced by 
an enlargement of some arteries, in consequence of a reduction of 
their tonicity (§ 325,) we may be led to expect that such enlargement 
may affect any part of the arterial system. We have chiefly hitherto 
considered determination in relation to the distribution of blood to 
parts ; but it may also occur in the great arterial trunks. Inordinate 
pulsation of the aorta, especially in the abdomen, at the cceliac axis, 
or at the bifurcation into the iliacs, (corresponding with a position a 
little below the epigastrium and at the umbilicus,) is a common symp- 
tom in nervous subjects, and may perhaps be accounted for by the 
observations of Valentin and Bernard, before quoted (§ 328.) I have 
frequently observed epigastric pulsation to occur before and after 
ha5matemesis. In several cases I have noticed the occurrence of ne- 
phralgia, hasmaturia, and lithic deposits in the urine, in patients af- 
fected with strong pulsation at the umbilicus. 

SYMPTOMS AND EFFECTS OF DETERMINATION OF BLOOD. 

333. Many of the symptoms of determination of blood may be in- 
ferred from the preceding illustrations. It generally causes a flush 
of heat in the part, and exalts the contractility (§ 112,) sensibility 
(§ 126,) and other nervous properties (§ 149,) sometimes exciting 
spasm, pain, irritation, and sympathetic disorder. In its moderate 
degrees, it increases the natural secretions of the part (§ 162,) and 
thus becomes the cause of mucous, bilious, and urinary fluxes, &c. 
The nutritive function is a slow process, and is only affected by de- 
termination of blood when* this is constant, or often repeated; then it 
is exalted in consequence, and more naturally than from congestion, 
the result being a simple and general hypertrophy of the part. Thus 
the arteries which are the channels of determination, and are at first 
only dilated, eventually become thicker in their own coats, and pre- 
sent in all respects larger dimensions. The process of absorption, 
although favoured when the blood-current is accelerated without dis- 
tention of the vessels, is nevertheless not equal to the task of re- 
moving the results of effusion caused. Hence determination of blood 
may cause dropsy in sacs and cavities. 

A few special examples will suffice to illustrate the symptoms and 
effects of local determination of blood. 

334. The parts most subject to determination of blood are those 
nearest to the heart in the distribution of their vessels, and those 
most freely supplied with blood (§ 30,) as for instance the brain, the 
parenchyma of glands, the mucous membranes, and the skin. 



286 



LOCAL HYPEREMIA — : 



DETERMINATION OF BLOOD. 



335. Determination of blood to the head takes place in some per- 
sons in consequence of mental excitement, violent exertion, the use 
of stimulant drinks, or from defective excretion. The symptoms vary 
considerably; but increased beating of the carotid and temporal ar- 
teries, some flushing of the face and suffusion of the eyes, and an in- 
crease of the symptoms on stooping, or lying with the head low, are 
present in all cases. The other symptoms are sometimes those of 
simple excitement of the nervous centres, painful throbbing in the 
head, excessive sensibility to light and sound, flashes in the eyes, 
noises in the ears, an excited state of the mind, a rapid flow of ideas, 
sometimes bordering on delirium, wakefulness or dreamy sleep, rest- 
lessness and irritability of temper. Sometimes they are those that 
indicate a temporary oppression of the nervous functions, such as gid- 
diness, drowsiness, stupor, imperfect vision and hearing, specks or 
mist appearing in the eyes, impaired articulation and powers of 
locomotion, and occasionally various convulsive affections, such as are 
present in hysteria and epilepsy. It has been before mentioned that 
fits of these disorders are not unfrequently produced by determina- 
tion of blood to the head (§ 153.) 

336. It may seem difficult to explain how such opposite symptoms 
as those of excitement and those of oppression, are produced by one 
and the same cause — determination of blood. But the explanation 
is really simple if the true nature of determination, and the different 
modes in which it affects the circulation within the head, are borne 
in mind. Moderate excitement of the brain, such as is induced by 
bodily exercise, mental exertion, or taking certain beverages, like 
tea and coffee, is accompanied by increased, but equal, flow of blood 
through the organ. But when these or other causes of excitement 
operate more energetically, the arteries supplying the brain are 
greatly dilated, and convey blood to it with more force, but without 
there being an equal increase in the quantity that passes through it; 
and this for two reasons. 1. As we have already seen, a certain de- 
gree of size and elasticity in the vessels best qualifies them to trans- 
mit blood freely (§ 301;) where this is wanting, increased force does 
not compensate for it, but only causes new disorder. Thus in violent 
palpitation of the heart, the aorta, carotid, and subclavian arteries 
are often dilated, and throb strongly; and so much force is then ex- 
pended on these larger trunks, that very little reaches their distant 
branches, as is proved by the weak pulse at the wrist. In the same 
way, in determination of blood to the head, the chief force is very 
apt to be expended in the larger vessels at the base of the brain, in- 
stead of being transmitted throughout its substance. 2. Another rea- 
son for the unequal or deficient excitement in determination of blood 
to the head, is the unyielding nature of the skull, which permits no 
great enlargement of some of the vessels within it, without a corre- 
sponding diminution of other vessels, and a general compression of 
the cerebral substance. Distention of the arteries, beyond a certain 
degree, compresses and obstructs the small veins, and thus prevents 
that freedom of circulation on which functional activity depends. 
Thus then is explained the production of symptoms of depressed, as 
well as of excited, energy of the nervous centres, besides occasionally 



EXAMPLES AND EFFECTS. 



237 



a mixture of both, by one and the same cause, determination of blood 
(§153.) 

337. Determination of blood to the kidneys is produced by the use 
' of stimulating diuretic drinks, and besides the increased flow of urine, 

may lead to pain in the loins and throbbing in the abdominal aorta; 
and the urine discharged may present an increase not only of its 
water, but also of its acid ingredient, as well as of epithelial cells 
thrown off from the uriniferous tubes, and in case of intense deter- 
mination of blood, such as that caused by the use of the most stimu- 
lating diuretics, such as turpentine, serum and even blood may be 
mingled with the urine. Dr. G. Eobinson has produced artificial al- 
buminuria in animals, by tying one of the common iliac arteries, 
whereby more blood was thrown upon the kidneys. Excitement of 
the circulation, by exercise or by nervous affections, also affects the 
kidneys; exercise necessarily causes the escape of much fluid from the 
skin; but nervous excitement, when it fails to cause perspiration, de- 
termines powerfully to the kidneys; and this probably is the explana- 
tion of the abundant flow of limpid urine which follows attacks of con- 
vulsive and other nervous affections. External cold operates in a 
similar manner; by constricting the superficial and extreme vessels, 
it directs the blood in unusual quantity and force on internal organs, 
especially the kidneys; and so produces enuresis. 

338. Determination of blood to mucous membranes is exemplified 
in certain forms of dyspepsia, in which sudden pain, heat, or nausea, 
is felt in the stomach, accompanied by epigastric pulsation, and some- 
times followed by the eructation of sour or other kinds of liquid, and 
sometimes by haematemesis. These attacks are often induced by ex- 
citement, general or local, following the use of irritant ingesta, and 
the application of external cold. A similar affection of the intestines 
causes a diarrhoea ; and of the air tubes, a bronchial flux ; it is a common 
character of these affections that they are suddenly produced under 
the influence of various exciting agents. 

339. Determination of blood to the skin often results, not only from 
direct irritation, but also from the influence of internal causes; as 
seen, for instance, in blushing from mental motion, in flushing of the 
face from the presence of acid in the stomach, and in the general 
redness of the surface upon reaction after exposure to cold, or at the 
commencement of fevers. In various chronic skin-diseases the effect 
of determination is marked in a brightening of the colour of the 
eruption; this sometimes takes place within a few seconds. 

340. Determinations of blood are commonly transient, coming on 
suddenly and soon subsiding. When they are more enduring, they 
often lead to other disorders. In their immediate seat they cause 
either increased secretion, with the addition to the secreted matters 
of more or less of the watery, saline, and albuminous parts of the 
blood, — or hemorrhage, — or they may even pass into inflammation. 
In other parts of the body, remote from the seat of determination, 
there is often, at first, coldness, defective circulation and impaired 
function (§ 330.) but afterwards a febrile reaction sets in, with hot- 
skin, accelerated pulse, scanty secretions, and other symptoms of in- 
flammatory fever. 

341. The frequent recurrence of determination of blood, or its long 



238 



LOCAL HYPEREMIA — DETERMINATION OF BLOOD. 



continuance in a slight degree, affects the structure in which it occurs; 
increased nutrition, — hypertrophy, — being the result. This may be 
a natural kind of hypertrophy, like that which happens to muscles 
that augment in size in proportion to their exercise, and the conse- 
quent circulation of blood through them. The uniform hypertrophy 
of the substance of the heart, and of other organs, after long-conti- 
nued excitement of the organ, may be referred to the increased de- 
termination of blood that has been kept up. In other cases parenchy- 
matous tissues, such as those that form the substance of the kidneys 
and liver, exhibit alterations rather than mere growth; albuminous 
deposits are formed, and granular degeneration results. In these 
and other instances the effect on the structure is generally modified 
by the presence of congestion, or inflammation, and by the plastic 
condition of the blood itself (§ 211.) 

It is unnecessary to dwell longer on the phenomena and results of 
determination of blood, because we shall have to- revert to them in 
speaking of the occasional consequences of the condition — flux and 
hemorrhage, — and of inflammation, of which it is a component part. 

REMEDIES FOR DETERMINATION OF BLOOD. 

342. In the treatment of all cases of determination of blood, as in 
that of diseases in general, it is obviously proper to attempt to remove 
the exciting cause, whatever that may be. Thus in the numerous 
class of cases which arise from the direct action of stimuli or irritants 
on the part which is the seat of the determination (§ 323,) the with- 
drawal of such irritants, or the diminution of their operation by the 
employment of soothing or diluent remedies, is a first indication. 

343. If we are correct in tracing local determinations of blood 
chiefly to an atonic distention of the arteries supplying the part (§ 325,) 
we may expect measures which promote the contraction of those ves- 
sels to prove efficient remedies. This is confirmed by experience ; 
the application of cold is one of the most effectual means we possess 
for subduing determinations of blood; and this has been mentioned 
as an important remedy for defective tone (§ 124.) Astringent ap- 
plications are equally useful in some instances of local determination; 
as seen in the use of solutions of acetate of lead, of sulphates of zinc 
and copper, of nitrate of silver, and of other constringing lotions as 
external applications (§ 326,) but these are chiefly effective when the 
determination is quite local and unconnected with generally increased 
circulation: under other circumstances they become irritants rather 
than astringents (§ 317.) According to the observations of Mr. 
Wharton Jones, a solution of sulphate of atropia and other prepara- 
tions of belladonna, promote the contraction of dilated arteries; and 
from their general therapeutic characters it is not improbable that 
arnica and tobacco possess a similar power, and might be used as an- 
tagonists to the morbid condition under consideration. The signal 
relief sometimes afforded by both these drugs, to inflammatory and 
painful irritations of the mouth, teeth, fauces, and skin, seems to prove 
that they exercise some control over determination of blood, as well 
as over nervous sensibility. 

344. Besides the employment of cold and other astringents as ap- 



T, E M E DIE S — DER IV ANT S — EYx\. CHANTS. 



239 



plications to the part which is the seat of the determination, and to 
the arteries leading to it, dcrivants, or means which draw away blood 
therefrom by relaxing other portions of the vascular system, are espe- 
cially pointed to by many preceding observations (§ 330, 331, 340.) 
Of these derivants, heat is the most effectual, especially when com- 
bined with moisture. Thus cold lotions or the cold douche applied 
direct to the head, and the employment of the hot foot-bath at the 
same time, constitute together the best treatment for determination 
to the head. Taking copious draughts of cold water, or more spa- 
ringly of iced water, will often relieve epigastric palpitation of the 
heart. The use of the warm bath, by deriving to the surface, dimi- 
nishes the flow of blood to the kidneys. I have known a severe at- 
tack of nephralgia instantly relieved by cold affusion on the loins; 
but the practice has too much hazard in it to be recommended. 

345. Various evacuant remedies may also be employed to coun- 
teract determination of blood, for these two determine a flow in ano- 
ther direction ; purgative diuretics and diaphoretics, thus often prove 
useful. Of these, purgatives are by far the most powerful and sure 
in their operation, and they are of great efficacy in determinations to 
the head. Change of posture may sometimes be made useful by ele- 
vating the part which is the seat of determination. 

346. But the most powerful derivant of all is blood-letting, general 
or local. The microscope may be made to show how opening a blood- 
vessel changes the course of blood; the currents in many vessels are 
reversed and drawn towards the bleeding point, whilst in others they 
are retarded where they were before running with great speed. But 
blood-letting is unnecessary, and even injurious, in many cases of de- 
termination of blood, especially such as are attended with a deficiency 
of blood in the whole system; and, as has been seen, such cases are 
not rare (§ 330.) Dry cupping is a good substitute in some such in- 
stances; but even this measure is more weakening than it is generally 
supposed to be, for by it much blood is extravasated into the skin 
and cellular texture, and is so really lost to the system as blood: its 
corpuscles being changed, and their structure destroyed. 

The cases in which blood-letting proves most beneficial are those 
where determination to an important organ is combined with some 
general plethora or local congestion, or where it has continued so 
long as to threaten to terminate in inflammation. A speedy blood- 
drawing, either by cupping or free venesection, will generally answer 
its purpose best. 

347. In the same class of cases, certain remedies are useful which 
seem to cause a general relaxation of the tonic fibres (§ 122) of the 
vascular system, and also an equalization of the force and quantity 
of blood which this system conveys (§ 331.) Antimony is the most 
powerful of these remedies; and its use is most indicated where fe- 
brile reaction has begun. 

348. Another class of remedies suitable for employment in deter- 
mination of blood, attended by much excitement, are sedatives, or 
such as reduce the heart's action (§ 115 ;) digitalis, aconite, hydrocyanic 
acid, and nitre, are of this nature. These are chiefly useful when the 
determination occurs in connexion with palpitation, as happens in the 
various convulsive or other sudden nervous attacks which I have 



240 



RESULTS 0E HYPEREMIA. 



shown to be so commonly excited by palpitation (§ 322.) I have 
entirely cured several cases of convulsive hysteria, and have much 
reduced the frequency of the fits in epilepsy, by using these remedies, 
sometimes combined with cold affusion to the head in the morning, 
and with the hot foot-bath at night (§ 331.) Hydrocyanic acid pro- 
bably operates chiefly on the organic excitomotory nerves, and, by 
lowering their function, prevents the undue excitement which they 
communicate to the heart. In this respect it surpasses conium and 
hyoseyamus, which are also sometimes useful in preventing determi- 
nation of blood arising from nervous excitement. 

349. We have found (§ 330) that in many instances determination 
of blood to internal organs results from weakness of the circulation, 
and especially from a want of tone in the whole vascular system 
(§ 123:) so that when cold constricts the external .vessels, or irrita- 
tions excite the internal organs, these latter monopolize most of the 
blood and force of the heart's action. In such cases, besides tempo- 
rary measures that tend to equalize the circulation, (as for instance 
the application of heat to the extremities and surface, of cold and 
astringents to internal organs, the employment of gentle exercise, 
friction, &c.,) more permanent influences are to be sought in tonics, 
and various particulars of diet and regimen, which act by giving 
strength to the contractile fibres (§ 124,) and by improving the quan- 
tity and quality of the blood (§ 271.) 

Thus preparations of iron and bark are useful remedies in the cases 
of greatest weakness: the mineral acids, iodide and bromide of po- 
tassium, mild bitters, and the lighter metallic tonics, nitrate of silver, 
sulphates of zinc and copper, and liquor arsenicalis, prove serviceable 
in others which do not bear the stronger tonics well. In using any 
of these remedies it is necessary to guard against their exciting ef- 
fects on the parts which are the seats of determination, by premising, 
or adding the temporary remedies (§ 242, &c.) suited to this morbid 
condition, and by keeping the secretions free and equally balanced. 

In all cases, country air, exercise adapted to the strength of the 
patient, and habits of posture that are opposed to the peculiar deter- 
mination, will be found serviceable to promote the removal and to 
prevent the recurrence of this kind of disorder. 



SECTION VI. 

RESULTS OF HYPEREMIA. 

350. Before proceeding to the consideration of the third and more 
complex variety of local hyperemia — inflammation — we must just glance 
at some remarkable results to which congestion and determination lead, 
when rendered intense to a certain degree, but stopping short of the 
conditions present in that third variety — I mean, hemorrhage, flux, 
and dropsy. These results have been already mentioned as sometimes 
ensuing from plethora, congestion, and determination of blood; and 
therefore in now recurring to them, it will be unnecessary to do more 
than exemplify their occurrence in connexion with these proximate 



HEMORRHAGE 



1 — EXAMPLES- 



! — CAUSES. 



241 



elements, and trace the further peculiarities which distinguish each of 
these results. 

I. HEMORRHAGE. 

351. The blood-vessels rnay, in any form of hyperemia, he distended 
to so great a degree, that their coats give way, and blood is then 
effused. I shall proceed to give illustrations of the more common cases 
of hemorrhage resulting from the several kinds of hyperemia which 
have been already described. 

General plethora (§ 275) not unfrequently causes hemorrhage, from 
the nose (epistaxis,) from the stomach (hwmatemesis, vomiting of blood,) 
from the rectum (hsemorrhois,) and into or upon the brain (apoplexy.) 
The operation in each of these cases, except the last, is more likely to 
be advantageous than otherwise, because it reduces the excessive ful- 
ness of the blood-vessels ; but it may be attended by unpleasant conse- 
quences and require control. 

352. Congestion from venous obstruction (§ 289) may produce 
hemorrhage in various situations. In this way pulmonary apoplexy 
(hemorrhage into the parenchyma of the lungs) follows upon obstruc- 
tive disease on the left side of the heart : bronchial hemorrhage and 
haemoptysis (spitting of blood) upon tubercles in the lungs ; hamate- 
mesis and bleeding piles upon obstructions of the liver and bowels 
occasioned by disease or violent straining. 

353. Congestion from weakness of the vessels (§ 290) often leads to 
hemorrhage in dependent parts, and in various textures during certain 
kinds of fever, and in debilitated subjects. Most passive hemorrhages 
are of this nature. A stooping posture has been known to cause cere- 
bral hemorrhage (apoplexy.) An erect one occasionally brings on 
uterine hemorrhage (§ 291.) 

354. The congestion of the head that follows the intropulsive opera- 
tion of cold (§ 292) sometimes issues in epistaxis and apoplexy ; that 
which results from previous excitement of the stomach and kidneys in 
drunkards (§ 294,) occasionally causes hpematemesis and hematuria 
(bloody urine.) The congestion of the kidneys incidental to scarlatina 
and the cold stage of ague, is sometimes followed by hematuria. 

355. Hemorrhage, from determination of blood (§ 322,) is exempli- 
fied in such cases of epistaxis and apoplexy as are preceded by increased 
beating of the carotids, flushing of the face, &c. (§ 335 ;) in hsematemesis 
induced by the action of irritants on the stomach (§ 338 ;) in hematuria 
brought on by stimulant diuretics (§ 337 ;) and in the bloody dysentery 
that sometimes follows the nse of drastic purgatives, &c. (§ 323.) So 
also we shall find hemorrhage to be a common concomitant or result 
of inflammation. 

356. But the cases of general or local hyperemia noticed above, do 
not of necessity result in hemorrhage: some essential element may be 
wanting ; and this element may be either in the blood-vessels or in the 
blood. 

357. The blood-vessels are sometimes obviously in a diseased state. 
When the arteries of the brain are inelastic and fragile, from osseous 
or fatty degeneration, or from aneurismal dilatation, they are very apt 
to become ruptured under the influence of congestion or determination 

16 



242 



RESULTS OF HYPEREMIA — HEMORRHAGE. 



of blood. When they are softened by inflammation or malnutrition, the 
blood-vessels of various structures readily give way : hemorrhage oc- 
curs on this account from an inflamed stomach or colon, in tubercu- 
lated lungs, in a softened brain, and in a diseased uterus. Occasionally 
actual ulceration or suppuration opens an artery or vein; this is by 
no means an uncommon cause of hemorrhage in chronic ulceration, in 
suppuration of lymphatic glands or tonsils, and in malignant disease 
of the stomach, intestines, and uterus. Mechanical injury may rup- 
ture blood-vessels in the kidneys and nostrils; hence hematuria and 
epistaxis sometimes follow violent blows in the loins or on the nose. 
I have repeatedly known hsematemesis to ensue upon the act of lifting 
a heavy body from a height, a proceeding which with peculiar force 
compresses the liver. 

358. But in other instances the hemorrhagic disposition can be 
traced to a peculiar state of the blood. Sometimes it is defective in 
fibrin (§ 196,) but abounding in red corpuscles ( § 184,) as in petechial 
fevers, congestive apoplexy, hemorrhagic small-pox, and other exan- 
themata. But there are other cases in which the disposition to he- 
morrhage prevails without any defect of fibrin or excess of red corpus- 
cles ; scurvy and purpura are examples of these. In scurvy indeed 
there is excess of fibrin and deficiency of red corpuscles (§ 185, 196.) 1 
It appears probable that an alteration in the quality of the red cor- 
puscles (§ 186) and fibrin (§ 203) is at the bottom of these in these diseases. 
The readiness with which textures become stained by the colouring 
matter, the purple, brownish, or particoloured blotches left by inflamma- 
tion, and, in extreme cases, the altered appearance of the blood itself, 
all seem to prove that the colouring matter of the blood is diseased ; 
the failure of the healing process, and the remarkably loose and blood- 
stained appearance of fibrinous coagula which form on the spongy gums, 
or in wounds, indicate that the fibrin is deficient in contractility and 
vital plasticity (§ 211.) Some microscopic observations have been al- 
luded to (§ 203, 187,) as bearing upon this subject; but more are needed 
for the completion of the inquiry. 

359. Another very important question connected with hemorrhage 
relates to the mode in which the blood gets effused. In some cases the 
blood-vessels are distinctly ruptured (§ 357.) But in other instances 
blood has been poured out in considerable quantities from mucous sur- 
faces, and even from the skin, without any discernible breach of ves- 
sels, or even of the surface. This has been observed particularly in 
epistaxis, in hasmatemesis, and in some remarkable cases of hemor- 
rhage from the skin, occurring successively at different parts of the 
body. Considering the size of the red corpuscles of the blood, and 
the absence of any visible pores in the walls of the blood-vessels, even 
when examined by the highest magnifying powers, it does not appear 
possible that those little bodies can escape from the vessels, without 
rupture either of their own walls or of the vessels. At the same time, 
it must be remembered that in the web of the frog's foot the red cor- 

1 In acute hemorrhagic purpura the fibrin is not deficient, for I have found that the 
"blood effused beneath the skin is firmly coagulated. I have before alluded to my expe- 
rience that purpura is generally connected with imperfect action of the liver ($ 171.) 



VARIETIES — STHENIC — ASTHENIC. 



243 



puscles are observed to pass through capillaries of calibre smaller than 
their short diameter : I have myself often seen them rolled up in the 
manner of a confectioner's ice wafer when so passing. J. Hewson 
noticed the flexible and extensible property of the red corpuscles, and 
his observation has been confirmed by his commentator, Mr. Gulliver. 
The appearances presented in capillary apoplexy (cerebral hemorrhage,) 
and hemorrhagic inflammations of serous membranes, countenance the 
opinion that many minute vessels become ruptured at once, probably 
in connexion with an altered condition of the blood: such minute rup- 
tures occurring in membranes might not be discernible by common 
modes of examination. All cases of this description that have lately 
come under my notice have included as an element, an altered state 
of the blood (§ 358,) generally of the nature of urasmia (171, 249) or 
cholaainia (§ 250.) Rokitansky and De Lange have noticed that in nu- 
merous cases of hemorrhages that came under their observation the 
blood-vessels were unusually delicate and vulnerable, and the blood at 
the same time abnormally thin. Mr. Paget has proved the existence 
of fatty degeneration of the small arteries of the brain in case of ce- 
rebral hemorrhage. 

VARIETIES OF HEMORRHAGE. 

360. Besides the differences in their seat, hemorrhages are distin- 
guishable into active or sthenic, and passive or asthenic ; and the pe- 
culiarities of these distinct varieties may be traced to the same struc- 
tural causes as the corresponding varieties of general and local hyper- 
emia, namely (§ 279,) excess or deficiency of the contractile power of 
the heart (§ 110,) and of the tonicity of the arteries (§ 120.) Thus 
hemorrhages preceded or accompanied by the symptoms of sthenic 
plethora (§ 280,) or by determination of blood (§ 322,) are active or 
sthenic; whilst those occurring in connexion with asthenic plethora 
(§ 281,) or with mere congestion (§ 287,) are passive or asthenic. The 
symptoms already described, when treating of these subjects, are there- 
fore the precursory symptoms of each kind of hemorrhage. 

361. But so soon as the hemorrhage begins, its occurrence may 
modify the previous symptoms in various ways, besides producing new 
ones locally through the discharge of blood. In active hemorrhage, 
the full, hard pulse of sthenic plethora acquires a remarkable jerk or 
thrill. This is very important when loss of blood is suspected, but 
cannot be seen. I have noticed this characteristic thrill in the pulse 
even when the loss of blood has been very trifling, and when no murmur 
has accompanied the heart's sounds ; and I am therefore inclined to 
think that it depends on an unusual abruptness of the heart's contrac- 
tion (§ 113,) combined with some irregularity in the tonicity of arteries 
in different parts (§ 326, 332,) which causes these to react in successive 
jerks at each pulse, instead of simultaneously. In fact, this same 
thrill is sometimes felt during a paroxysm of determination of blood to 
a part when no hemorrhage accompanies it. 

If the quantity of blood effused be large, and especially if its loss 
be rapid, actual syncope, or various slighter degrees of faintness and 
weakness, may ensue. The pulse too becomes small, weak, and often 
irregular, and the surface and lips pale; either consciousness, or the 



244 



RESULTS OF HYPEREMIA — HEMORRHAGE. 



heart's action, may be the first to fail, according to the posture of the 
patient at the time (§ 70,) and the condition of anemia (§ 262,) is in- 
duced. 

362. Even after this faint state has been produced, increased action 
(reaction) will return in the course of a few hours ; and it is in this that 
the pulse exhibits the greatest degree of the jarring or vibratory cha- 
racter; so that it may feel like a loose wire twanging, or a rough file 
drawn, under the finger. With this state of the pulse, palpitation, 
throbbing of the great arteries, and the various symptoms of local ner- 
vous excitement described under the head of ansemia, are very apt to 
occur (§ 266.) During this reaction the hemorrhage maybe renewed. 

363. If the hemorrhage is inconsiderable, or if it be suddenly checked 
by styptics before the vascular fulness or determination has been re- 
duced, inflammation may ensue, accompanied by increasing strength 
and hardness of the pulse, heat of skin, and other symptoms of inflam- 
matory fever. On the other hand, hemorrhage, if it be considerable, 
may remove the hyperemia, and relieve the sense of fulness, tightness, 
and pain, the functional derangements and the other local and general 
symptoms of oppression, which it had produced. Thus headache and 
flushing are often relieved by epistaxis ; cough, pain, and oppression 
in the chest by haemoptysis ; abdominal pain and pulsation by hema- 
temesis, melena, or hemorrhoidal flux. 

364. But the blood effused may produce various disturbances in the 
parts into which it is poured. When the hemorrhage is within the 
head, it of necessity causes pressure on the brain ; and by interrupting 
the circulation through it, it may induce coma or paralysis (§ 273;) 
or it may at once break up the cerebral substance, and so cause death 
by syncope (§ 116) and asphyxia combined. When it is in the lungs, 
the blood may at once suffocate by its quantity, or it may cause dys- 
pnoea and cough until it is expectorated. Here, too, it sometimes 
mechanically breaks up the texture of the organ and leads to serious 
disorganization. When it is in glands it forms swellings, or is mixed 
with, and modifies, the secreted matters, as seen in the case of hema- 
turia. Hemorrhage into other complex textures produces swelling, 
not uncommonly followed by local inflammation ; this is instanced in 
the cutaneous blotches of purpura hemorrhagica. 

365. Passive or asthenic hemorrhage may be preceded by symptoms 
of asthenic plethora (§ 281) or congestion, and may be accompanied 
by symptoms of exhaustion, if the loss be profuse, or of relief, if it be 
moderate; anemia may ensue from excessive loss; reaction, sthenic 
hemorrhage, or inflammation, maybe the result, if the bleeding be too 
suddenly checked. The hemorrhage connected with an altered state 
of the blood is generally of the passive kind, although excitement, or 
determination of blood (molimen hcemorrhagicum,) sometimes occurs 
here also. 

TREATMENT OF HEMORRHAGE. 

366. As hemorrhage is commonly a result of plethora, congestion, 
or determination of blood, the remedies for those morbid elements will 
be as commonly more or less needed in its treatment. But the demand 
for their use will very much depend on the extent and seat of the he- 
morrhage, and the mischief likely to result from its continuance. For 



EFFECTS — TREATMENT. 



245 



example: a moderate epistaxis or hemorrhoidal flux needs no treat- 
ment; it is a natural cure for a previously existing hyperemia. But 
if either of these be profuse, they must be restrained, and equally so 
whether they be of the sthenic or asthenic kind : if sthenic, by artificial 
bleeding, and by derivation to other parts, both of which measures re- 
duce the fulness which causes the hemorrhage: if asthenic, by the use 
of styptics, combined with derivant measures, in order that the loss of 
blood, which is injuring the system, may be stayed. 

867. In some cases, however, hemorrhage to even the slightest 
amount may be injurious, and therefore must be opposed from the first, 
both by remedies for the hyperemia, which is the cause of the hemor- 
rhage (§ 845, et seq.,) and by styptics, which peculiarly counteract this 
result. Hemorrhage into the lungs, the brain, or any other internal 
vital organ, requires prompt interference. So also does excessive he- 
morrhage of any kind under all circumstances, and more moderate loss 
in very weak subjects. In all of these cases the continued flow of 
blood may be attended by urgent danger. 

368. In active hemorrhage, blood-letting may generally be persevered 
in until the flow is arrested, or the pulse reduced ; and the effect should 
then be sustained by the influence of other evacuants, especially pur- 
gatives and diuretics. Remedies which diminish the power of the 
heart, such as digitalis, hydrocyanic acid, and nitre, and those which 
also reduce the tonicity of the arteries, especially preparations of anti- 
mony, are likewise of great use in some forms of active hemorrhage. 
Another powerful agent for the arrest of hemorrhage, connected w T ith 
increased action or determination of blood, is cold (§ 343.) Thus ice, 
or a stream of cold water applied to the nose and forehead, is of great 
efficacy in epistaxis ; ice taken into the stomach, in hssmatemesis ; ice 
employed externally, or the injection of ice-cold water, in uterine he- 
morrhage (§ 344.) I do not however approve of the practice recom- 
mended by some, of applying ice to the walls of the chest during hae- 
moptysis ; I have known pneumonia thus induced, and the resulting 
consolidation is apt to run into rapid consumption. Cold water is 
sometimes very effectual in arresting the flow of blood from a wound ; 
Dr. 0. Rees has suggested that in this case in addition to its direct 
constringent operation on the vessels, it may possess the power of ar- 
resting the capillary circulation in consequence of the red corpuscles 
being made to swell up by the influence of osmose. 

The treatment of passive or asthenic hemorrhage, besides the employ- 
ment of styptics to prevent excessive loss of blood, includes also the 
use of remedies for general plethora (§ 286,) or local congestion (§ 313, 
&c.) which may be the cause of the hemorrhage. Hence general or 
local depletion, and derivant medicines, accompanied or followed by 
tonics, are commonly useful. 

869. We have now to consider the means that are calculated to re- 
strain all kinds of hemorrhage, but which are more especially adapted 
to arrest the flow when it has been caused through disordered circu- 
lation (§ 356.) If the blood-vessels are softened, brittle, or actually 
ruptured or ulcerated (§ 357,) the chief thing to be done is the dimi- 
nution of the quantity of blood sent to them ; and, besides the employ- 
ment of blood-letting, this may be effected by pressure, regulation of 



246 



RESULTS OF HYPEREMIA — HEMORRHAGE. 



the posture, cold and astringent applications, and the use of measures 
calculated to tranquillize the whole circulation. Thus epistaxis is some- 
times arrested bj pressure on the carotids; uterine hemorrhage by 
pressure on the abdominal aorta, or by elevating the pelvis; haemop- 
tysis by keeping the chest high. In all cases of hemorrhage, perfect 
stillness and a cool regimen are indispensable. 

370. The other pathological condition which inclines to hemorrhage, 
— an altered state of the blood (§ 358,) — is perhaps more directly in- 
fluenced by the administration of remedies called styptics. Most of 
these remedies are astringents, and act by causing contraction of the 
tonic fibres of vessels and other parts, but some of them also render 
the blood more plastic and coagulable, and then exercise a twofold in- 
fluence over the mischief. 

Of those medicinal agents which cause both contraction of the vessels 
and increased coagulability of the blood, the most powerful are acetate 
of lead, alum, sulphate of copper, chloride of zinc, and nitric and sulphu- 
ric acids. Other styptics, as for instance nitrate of silver, sulphate 
of zinc, sulphate of iron, and infusion of nutgalls, are certainly astrin- 
gent, but they have also been generally supposed also to coagulate the 
blood ; Mr. Blake's experiments however show that they have not this 
latter effect when injected into the veins of living animals (see note to 
§ 214.) When applied topically, they coagulate the blood in the bleed- 
ing vessels. Nitrate of silver acts in this way upon leech-bites; so also 
does the actual cautery. But this influence cannot be exerted upon the 
blood in the channels of the circulation, or it would produce the most 
dire results. There, no doubt, the coagulating power is restrained by 
some antagonistic forces; but it is allowed to come into play as the 
astringents pass out of the blood through the terminal capillary vessels, 
or other channels. 

In some cases of hemorrhage, the styptic remedies may be applied 
directly to the bleeding part, as in epistaxis, haematemesis, hemor- 
rhoids, and uterine hemorrhage. In epistaxis, solutions of alum, ace- 
tate of lead, and sulphate of zinc, are sometimes injected into the nos- 
trils, or applied by sponge or lint. In haematemesis, sugar of lead, 
alum, gallic acid, creosote, oil of turpentine in small doses, and the 
mineral acids, may be given by the mouth, so that they operate directly 
on the bleeding part. In excessive hemorrhoidal flux, enemata, con- 
taining some of the same remedies, are immediately beneficial. Oil of 
turpentine scarcely ever fails to stop the bleeding which in some cases 
continues into the socket after the extraction of a tooth. 

371. In many instances; the bleeding part is beyond the reach of 
the direct application of styptic remedies : yet some of them may be 
made to exercise considerable power in restraining the hemorrhage 
through internal administration. Thus haemoptysis is assuredly some- 
times checked by frequently repeated doses of sugar of lead (which 
should be combined with a little opium or conium, to prevent its 
griping the bowels;) and more uncertainly by ipecacuanha, gallic acid, 
alum, and other astringents. Haematuria of the passive kind is dimi- 
nished by small doses of oil of turpentine ; passive uterine hemorrhage 
by gallic acid, ergot of rye, and tincture of the sesquichloride of iron. 
Opium given internally has been found effectual in some cases of ute- 



REMEDIES — ACTION OP GALLIC AND TANNIC ACIDS. 



24T 



rine hemorrhage. It is difficult to explain how it operates ; but it is 
probably through the same astringent property that enables it to di- 
minish many of the secretions. It is a remarkable fact that all astrin- 
gent medicines that exercise a restraining effect over hemorrhage, as 
well as other excessive flows, possess the power of precipitating albumen 
from solution. Every one of the mineral astringents does this. And 
so also do turpentine, creosote, and tannic acid. It is highly probable 
that astringents cause contraction of muscular fibres, and act on the 
tonicity of tissues through this chemical influence over albumen, and 
that so their constringent and coagulating powers are but modifications 
of the same force. When these coagulating agents are administered as 
internal remedies, they act immediately on the mucous membranes 
with which they come in contact, before entering the blood. Then in 
the blood their coagulant influence is kept in abeyance, but it comes 
into play again as they issue from it, and so produces its peculiar ef- 
fects on the structures through which they are thrown out. Hence 
when astringents are to be successfully employed as internal remedies 
they must be in such quantity, that even after dilution in the general 
mass of the blood, they may be still capable of exerting a decided in- 
fluence upon the organs or parts for which they are designed. Hence 
in a general way those medicines are most extensively applicable that 
are comparatively harmless in themselves when introduced into the 
blood; alum, the salts of iron and tannic and gallic acid are of this 
nature. In cases of hemorrhage the preparations of iron are especially 
pointed out as likely to be of great service, where there is time to se- 
cure their results, because they tend to hasten the reproduction of the 
red corpuscles, at the same time that they constringe the parts that 
are the outlets of the flow. These preparations are also of farther 
value on account of the readiness with which they can be combined 
with sulphuric and hydrochloric acid, as in the muriated tincture, and 
in acid sulphate of iron. Creosote is a powerful astringent, but it can 
hardly be given in sufficient internal doses to produce an effect on a 
remote part of the system, because it has powerful influences as a neu- 
rotic ; it however is very efficient in restraining hemorrhage from the 
part to which it can be applied, namely, the mucous membrane of the 
stomach. Sulphuric acid acts principally upon the mucous membranes, 
but while in the blood, it is certainly combined with alkalies into neu- 
tral salts that are not astringent, hence when it acts upon any part as 
an astringent, after having been in the blood, it does so because that 
part has the power of resolving the neutral salt and separating it again. 
Most of the vegetable astringents owe their properties to tannic or 
gallic acids; of these two compounds tannic acid has proved itself to be 
the most powerful agent when used externally, and gallic acid when 
administered through the blood. And yet tannic acid is now known 
to be merely gallic acid plus something else. M. Braconnot has shown 
that tannic acid is merely gallic acid combined with the elements of 
grape sugar (C 12 0 12 H 12 .) Six atoms of gallic acid and one molecule 
of grape sugar make three atoms of tannic acid. M. Pelletier has 
successfully solved the enigma of the gallic acid, which does not coagu- 
late albumen by itself, being nevertheless so valuable an agent when 



248 



RESULTS OF HYPEREMIA. 



administered through the blood. He has shown that a mixture of gallic 
acid and of solution of gum coagulates liquid albumen, although neither 
of the two can do so alone (see Turner's Chemistry, 7th ed., p. 995.) 
But gum is chemically identical with grape sugar, or very nearly so ; 
and grape sugar is always present in the blood. Gallic acid of ne- 
cessity becomes tannic acid when mingled with the blood, and then be- 
comes chemically coagulant or astringent. It has on the other hand very 
little power when externally applied, because it then does not find the 
material necessary for its conversion into tannic acid. Tannic acid 
already prepared may be employed externally, and for the alimentary 
and genital passages. The astringent property of gallic acid may be 
directed on a particular secreting organ by combining it with an agent 
which acts on the secretions of that organ. Thus in hematuria it 
should be conjoined with a diuretic, and the bitartrate of potass, which 
is not stimulating, is very fit for this purpose. It is probable that uva 
ursi, buchu, and pareira, owe their efficacy in diseases of the urinary 
organs to a similar combination of an astringent with a diuretic action. 

372. In some kinds of hemorrhage, as in intestinal fluxes, remedies 
which increase the proper secretions of the canal and of its glandular 
allies, such for instance as mercurial and saline purgatives, prove to be 
the most effectual, particularly if combined with others of a styptic 
kind, like sulphuric and nitric acids, alum, and sulphate of zinc. This 
mode of treatment is often sufficient for the cure of slight hemorrhages, 
or for obviating dispositions to hemorrhage from the lungs and uterus, 
or from the textures affected in purpura hemorrhagica ; and it doubtless 
acts through its influence on the condition of the blood, as well as by 
its evacuant and styptic powers. 

II. FLUX AND DROPSY. 

373. Another result of the various kinds of hyperemia, is an effu- 
sion of the watery part of the blood holding more or less animal and 
saline matter in solution. This result, occurring in secreting organs 
or from open surfaces, constitutes fluxes; in closed sacs or in the cel- 
lular connective texture, it constitutes dropsies. There is so much 
that is common in the pathology of fluxes and dropsies, that a great 
deal of repetition may be avoided by speaking of the two together in 
the first place ; and then afterwards their distinguishing peculiarities 
may be advantageously noticed apart. 

374. General plethora sometimes leads to flux or dropsy ; but these 
results most commonly ensue where the blood-vessels are temporarily 
distended with blood containing an undue proportion of water. Thus, 
if water be gradually injected into the veins of a living animal, the 
circulation and breathing become embarrassed ; and after a time drop- 
sical effusions take place into the abdomen, the chest, and the connec- 
tive tissue ; or a flux occurs from the kidneys, intestines, or skin ; or 
several of these results happen together ; and the blood-vessels so get 
relieved of their distention. The same effects have sometimes been 
produced by excessive drinking, especially when the kidneys and the 
skin, the natural emunctories for superfluous fluid, have at the same 
time failed to perform their usual office. Thus drinking largely of a 
cold liquid when the body is perspiring and fatigued, is very apt to 



FLUX AND DllOPSY. 



249 



weaken the heart's action, and to check the cutaneous and renal secre- 
tion ; the blood-vessels then become filled to distention, and not uncom- 
monly relieve themselves by dropsical effusions or diarrhoea. Cold ex- 
ternally applied sometimes operates in precisely the same way; it first 
arrests perspiration, and causes internal congestions (§ 292;) and if, 
from previous over-excitement or other disorder, the kidneys are un- 
equal to take upon themselves extra work to compensate for the skin's 
default, general fulness is the result, which tends to find issue in some 
dropsy or flux. The sudden suppression of a cutaneous eruption, or 
of the discharge from an old ulcer, has sometimes been followed by 
anasarca, diarrhoea, or bronchial flux (humid asthma.) The colliqua- 
tive sweats of advanced phthisis are of the nature of a flux ; the blood- 
vessels, in their obstructed and weakened state, thus relieve themselves 
of superfluous liquid. These sweats may generally be stopped by a 
judicious restriction of liquid ingesta and an avoidance of too warm 
clothing. 

375. Instances of local congestion terminating in flux and dropsical 
effusion are afforded in almost every variety of this condition that has 
been already enumerated (§ 288, et seq.) In fact, such is the most 
common cause of partial dropsies. 

The adequacy of venous obstruction to produce dropsy was well 
illustrated in some experiments of Lower. He had tied the jugular 
veins of a dog, in the expectation that the animal would die of apo- 
plexy ; instead of this result, however, its face and head became swelled 
with considerable oedema. He then tied the ascending vena cava; 
and ascites and anasarca of the lower extremities were the consequences. 
Disease affords numerous examples of dropsy and flux being produced 
by venous obstruction. Aneurisms of the arch of the aorta, or other 
tumours, that press on the vense innominate, or descending vena cava, 
sometimes cause oedema of the face and upper extremities. In a case 
(which was under my own care) of malignant tumour involving the 
roots of the lungs, there were hydrothorax, and flux into the bronchial 
tubes (bronchorrhcea.) In advanced pregnancy and ovarian dropsy, 
the legs commonly swell in consequence of the pressure of the tumour 
on the iliac veins. Many instances are recorded in which the occlu- 
sion of a large vein was followed by dropsy of the part from which the 
vein proceeded. The ascending vena cava has been found obliterated 
in persons who had long been affected with ascites and anasarca of 
the lower extremities. In the University College collection, there is 
a drawing of such a case, in which a supplementary circulation had 
been established by means of an enormous enlargement of the super- 
ficial veins of the abdomen. Dr. Watson relates an instance of the 
same kind. 1 M. Tonnele has made some observations which favour 
the notion that chronic hydrocephalus may be caused by a partial ob- 
literation of the venous sinuses of the head (§ 267.) Mr. Gulliver in- 
forms me that he has in many instances traced extensive oedema of the 
lower extremities to obstructions by clots, mostly fibrinous, in the iliac, 
femoral, or popliteal veins. 2 

1 Library of Medicine, Art. "Dropsy," vol. v. 

2 Med. Chir. Trans., 1839. 



250 



RESULTS OF HYPEREMIA. 



But the most common causes of venous obstruction are certain vis- 
ceral diseases, and these are commonly attended by either dropsy or 
flux. Contractile disease of the liver, cirrhosis, is the most frequent 
of all causes of simple ascites ; and diarrhoea and gastrorrhoea (watery 
eructations) are very apt to occur in connexion with various functional 
and structural diseases of the liver. Structural disease of the heart, 
especially if seriously affecting the orifices or valves, commonly leads 
to hydrothorax, bronchial flux, (humid asthma,) and sometimes even 
general dropsy. Pulmonary congestion, induced by circumstances that 
impede the respiration (§ 298,) such as spasmodic asthma, emphysema, 
laryngitis, hanging, and coma, sometimes results in a bronchorrhoea or 
hydrothorax. In the experiments of Dr. J. Reid, a serous flux into 
the bronchial tubes ensued after the division of the par vagum; this 
was a consequence of the impaired respiratory action, inducing pulmo- 
nary congestion. 1 

376. As congestion arises from weakness of the circulation and atony 
of the vessels (§ 290,) so dropsical effusions and fluxes proceed from 
the same causes. Thus oedema of the lower extremities is a common 
sign of extreme weakness; as seen after severe illness, and towards the 
fatal termination of many chronic diseases. Colliquative diarrhoea 
and perspiration (fluxes) sometimes occur under similar circumstances. 
The oedema and fluxes which arise from weakness are more readily in- 
duced by postures which cause gravitative congestion in the affected 
parts. Thus continued standing causes swelling of the legs, and leu- 
corrhoea, in persons liable to these affections. 

377. Fluxes and dropsical effusions sometimes occur after previous 
excessive excitement of the vessels of a part. Hence oedema after 
erysipelas, and the infiltration of serum into cavities and textures after 
great activity of the vessels of these parts, even when no inflammation 
has been present. The gleets or fluxes which follow inflammations of 
the urethra, bronchi, alimentary canal, and vagina, seem to be con- 
nected with precisely the same condition of the vessels that sometimes 
causes congestion (§ 294.) Persons who indulge in spirituous liquors 
often suffer in the morning from waterbrash, and find a glass of spirits 
the best remedy for it: in this case, however, obstruction in the liver 
(§ 56, 371) may have to do with the result. 

378. Fluxes sometimes arise from the intropulsive operation of cold 
(§ 77, 292 ;) diarrhoea and catarrhal affections, too transient to be in- 
flammatory, are frequently thus induced; ordinary diuresis (flux of 
urine) is an example of the same influence, although in this case an 
operation of undisturbed health. It is doubtful whether cold suffices 
in this way to cause dropsy; but it may increase it where it existed 
previously. 

379. The other variety of local hyperemia, determination of blood 
(§ 321,) also produces fluxes and dropsies. The influence of various 
stimulants on secreting organs and surfaces illustrates this (§ 324.) 
Thus snuff taken into the nose determines a flow of nasal mucus and 
of tears ; spices in the mouth provoke a discharge from the salivary 
glands ; the inhalation of irritating vapours causes a flux in the air- 

1 Edin. Med. and Surg. Jour., vols. 49, 51. 



FLUX AND DROPSY — EXAMPLES. 



251 



tubes ; purgative medicines induce a flux from the intestines, &c. In 
these cases, the irritation is short of inflammation, a state which, 
although attended with determination of blood and effusion, also com- 
prises other conditions. The fluid thus secreted in fluxes from deter- 
mination of blood, differs from the products of inflammation: it com- 
monly consists of the natural secretion of the part diluted with an un- 
usual proportion of water, and loaded with saline matter derived from 
the blood ; the excess of saline matter sometimes gives to the secretion 
an irritating quality, as instanced in the discharge of coryza, bronchor- 
rhoea, and watery diarrhoea. 

Other examples of flux may be referred to determination of blood 
unconnected with special irritation; such is the leucorrhoea which pre- 
cedes and follows the menstrual period, the bronchorrhoea or gastror- 
rhoea excited in some cases by increased action of the heart, and the 
sweat succeeding to flushes of blood to the head or other parts. 

380. Dropsy is not so commonly a result of simple determination of 
blood ; because, independently of inflammatory action, there are com- 
paratively few circumstances that can throw increased flow of blood 
upon closed sacs. But probably the dropsy that accompanies tuber- 
cular deposits in the peritoneum and membranes of the brain may be 
partly induced by the mechanical irritation of the tubercles causing a 
flow of blood to the membranes. The sudden manner in which tuber- 
culous hydrocephalus sometimes makes its attack seems to countenance 
this opinion; for this affection is unquestionably attended by the phe- 
nomena of determination of blood to the head, already described (§ 323.) 
The kinds of dropsy called inflammatory may be included under the 
same head; but we shall shortly see that the determination of blood, 
or excitement of the circulation, present in such cases, is itself conse- 
quent on an altered condition of the blood. 

381. As flux and dropsy commonly arise from similar conditions of 
the vascular system, so they are sometimes found to succeed one an- 
other. Thus Andral mentions a case in which hydrothorax was re- 
moved on the occurrence of a profuse flux from the air passages. Ex- 
amples are not uncommon of the subsidence of ascites on the occurrence 
of diarrhoea, or of the supervention of ascites when a diarrhoea of long 
duration has been suddenly checked. Dr. Watson quotes from Dr. 
Farre's lectures an instance in which hydrocele was removed by violent 
purging. It is a familiar fact that the occurrence of dropsy is com- 
monly attended by a marked diminution of the urinary secretion, and 
that a return of its free flow is often connected with a reduction of the 
dropsical effusion. A knowledge of these several facts points out the 
most effectual treatment for dropsy. 

382. It has been stated that flux, dropsy, and hemorrhage, are oc- 
casional results of the different varieties of hyperemia. But what are 
the circumstances which determine the precise nature of the result in 
any case? We have seen that the additional or determining cause of 
hemorrhage is either in the vessels or in the blood (§ 350.) So also 
similar conditions may incline to the occurrence of flux and dropsy. 
An extreme amount of vascular distention pretty certainly results 
either in rupture and hemorrhage, or in the exudation of the watery 



252 



RESULTS OF HYPEREMIA. 



parts of the blood (§ 305, 840 ;) the long continuance of congestion or 
plethora too, by making exhalation predominate over absorption, rarely 
fails to lead to like consequences. But both dropsical effusions and 
fluxes sometimes take place with a facility that is disproportioned to 
either the amount or duration of hyperemia ; in these cases the cause 
may be traced to a generally lax, flabby state of the tonic and con- 
tractile fibre (§ 128,) to a poor, watery state of the blood (§ 222,) or 
to both these conditions acting together. Persons liable to these af- 
fections are usually of pale complexion and phlegmatic temperament 
(§40.) 

The influence which relaxation of the solids has in producing profiu- 
vial and hydropic disorders, is exhibited in their occurrence in organs 
after over-excitement (§ 294,) when there is no indication of general 
disease of the blood. But in cases in which the blood is diseased, there 
is usually also a relaxed state of the vascular fibre ; and it is not then 
easy to distinguish the exact influence of each of these causes in the 
production of the result. The liability to dropsy and fluxes which is 
present after long fevers, defective nourishment (§ 63, 196,) or con- 
finement in impure air, must be attributed to the joint operation of 
both classes of causes indicated above. 

383. The conditions of blood which predispose to watery effusions 
require farther consideration. A poor or watery state of the blood, is 
the most obvious of these: and that this alone is sufficient for the effect 
is plain, from the fact already noticed, that injecting water in conside- 
rable quantity into the veins of a living animal, will cause effusions or 
discharges; the injection of blood or serum in the same way does not 
lead to the same result. Persons who have lost much blood are liable 
to become dropsical, because the bulk of the lost blood is replaced by 
watery serum absorbed from various sources, which thus renders the 
mass of the liquid more dilute (§ 264,) and because the solid consti- 
tuents of the blood are removed much more rapidly under such circum- 
stances than the water (§ 192.) Watery blood tends to produce dropsy 
and flux, not merely because thin fluids have greater proneness to 
transude through the Avails of the vessels, but also on account of the 
failure and irregular distribution of the force of the circulation. It 
has been already explained, under the head of anaamia (§ 262,) that a 
scantiness of blood embarrasses the circulation. The structure of the 
heart and its valves, and of the vessels, is adapted to act upon a certain 
spissitude and quantity of the blood ; and when these vary much from 
the natural standard, — when the blood instead of being of an unctuous 
fluidity, is watery and squashy, — the hydraulic moving apparatus is 
less capable of effecting its propulsion: it has been experimentally as- 
certained that liquids with a certain amount of thickness, run in narrow 
channels more freely than thinner ones, or pure water. A thin condi- 
tion of the blood may thus by diminishing onward flow, not only faci- 
litate watery effusions, but also promote the congestions and other de- 
rangements in the circulation with which flux and dropsy are commonly 
connected. 

384. Several of the circumstances which induce a thin state of the 
blood have been already stated (§ 222, 249, 882,) but in relation to 



DROPSY WITH ALBUMINURIA. 



253 



dropsy, it is of more importance to consider what proves to be a more 
frequent cause, namely imperfect excretion by the kidneys, liver, and 
skin. In various forms of hyperemia which lead to dropsy and flux, 
(plethora, congestion and determination of blood,) it will be generally 
observed that these results ensue in proportion as the excreting organs 
fail, and that the removal of the dropsy or flux is most certainly en- 
sured by the employment of measures which restore, or compensate for 
the defective excretion. Exposure to cold is very commonly followed 
by dropsy; and at first sight this might seem to operate merely by 
checking perspiration, and thus retaining in the vessels water that 
should be eliminated, and which is then effused within the body. But 
checked perspiration alone will not cause dropsy : there must be a failure 
at the same time in the action of the kidneys, before this result will 
ensue. If these perform their office properly, checked perspiration may 
disorder the circulation, and cause congestions, inflammations, and even 
fluxes ; but I have never met with a case of dropsy arising from ex- 
posure to cold, in which there was not a deranged condition of urine ; 
in the great majority of instances, it was albuminous. 

The circumstances in which exposure to cold is most liable to induce 
dropsy, are such as also tend to impair the action of the kidneys at the 
same time. A man in a fit of intoxication lies for several hours of the 
night on the cold damp grass; he arises much chilled, has shivering 
succeeded by fever, and general dropsy soon after ensues: the urine is 
very scanty, and on examination is found to be highly albuminous. 
Here the vital powers of the kidneys had been exhausted by the ex- 
citement of the stimulant beverage, so that when cold checked the per- 
spiration and threw the blood on internal organs, these in particular 
could not take upon themselves their vicarious and compensatory office ; 
and so their vessels became distended with blood and mechanically 
exuded serum, instead of separating the proper constituents of urine 
(§ 309 ;) these and the superfluous water accumulate in the blood, and 
alike by their undue quantity and irritating qualities, cause effusions 
of serum with urea in different parts of the body, as well as producing 
other functional disorders before noticed (§ 170.) In all cases of this 
nature, the danger is strictly in proportion to the evidence of renal 
derangement and disorganization. It is much greater when the urine 
discharged is alkaline, phosphatic and highly albuminous, than when 
it is still acid and depositing lithates with epithelial scales, and even 
blood corpuscles in addition to the albumen. In this latter case there 
is much more chance that the disordered organ may yet right itself. 

Another instance of a similar kind of general dropsy is that which 
supervenes after scarlatina. This has been ascribed by some to a sub- 
inflammation of the cellular tissue, originating in the eruption; by 
others to the diseased state of the skin, which is left by the eruption, 
suppressing the perspiration. But if either of these were the true 
cause, the dropsy ought to occur most in the cases in which the erup- 
tion is most abundant; this however is by no means the fact; nay I 
have had occasion to treat several patients in whom anasarca has fol- 
lowed a scarlatina fever, with sore throat, in which there was no rash 
at all. In all these cases the urine was albuminous, and this again 



254 



RESULTS OF HYPEREMIA. 



shows that the diseased action of the kidney is the most essential lesion 
connected with general dropsy. How scarlatina impairs the function 
of the kidney is a question too extensive to be discussed here ; but I 
will simply state my belief that it does so by causing a highly congested 
state in these glands, which injures their secreting power (§ 304,) much 
as happens with regard to the liver in bilious and intermittent fevers. 
A female who was under my care with albuminuria, which was almost 
cured, was attacked with mild scarlet fever: the urine, which had been 
merely hazy under the influence of heat and nitric acid, immediately 
became highly coagulable, and continued so until the fever declined, 
when the albumen again gradually decreased. 

It has been remarked by several observers that in the early stages 
of albuminuria, whether after scarlatina or from other disorders causing 
great congestion of the kidneys, the urine also contains an abundance 
of the epithelial cells of the uriniferous tubes, either detached or agglu- 
tinated together in the shape of casts of the tubes. This desquamation 
of the uriniferous epithelium for the time impairs its secreting power; 
hence the urine is diminished, whilst the congested Malpighian bodies 
still pour out water, containing more or less albumen, and in some 
cases even red corpuscles. The disposition to this escape of blood cor- 
puscles is favoured by their altered and partly broken condition (§ 187,) 
which is also a cause of petechias and other hemorrhages in scarlatina. 
In cases where the vitality and nutrition of the organ are unimpaired, 
the uriniferous tubes soon become furnished with a new and active epi- 
thelium, and the secreting power is restored, whilst the removal of the 
congestion causes the disappearance of albumen from the urine. But 
under the opposite condition of low vital power and mal-nutrition, the 
epithelium may not be renewed ; the proper secreting power of the tubes 
is not recovered, and they continue to let pass the mere watery exuda- 
tion of the Malpighian bodies, with more or less albuminous impregna- 
tion according to the fulness of the blood-vessels. Thus in cases of 
confirmed albuminuria many of the uriniferous ducts have been found 
without any epithelium. Besides these changes, fibrinous deposits and 
fatty degenerations occasionally ensue in the kidney, which it is not 
necessary to particularize farther in this place. 

The general dropsical state which occurs towards the fatal termina- 
tion of structural disease of the heart, I have in several cases found to 
be connected with albuminuria and slight jaundice, and I have been 
long in the habit of pointing out these as the most surely fatal com- 
plications to which heart diseases naturally tend; their connexion has 
been before noticed (§ 305, 309.) 

385. The pathological effects of the secretion of serous and scanty 
urine (oliguria) have been already described (§ 1T0, 249,) but we must 
more particularly advert to the mode in which it induces dropsy and 
flux. When dropsy results from a suddenly operating cause, such as 
exposure to cold, or scarlatina, a febrile state is generally present, with 
a frequent and hard or sharp pulse, heat of skin, thirst, &c. These 
symptoms, occurring in connexion with the anasarca, have led to the 
use of the terms inflammatory, febrile, acute, or active dropsy ; and so 
far as these are taken as merely implying the presence of an excited 



DROPSY WITH ALBUMINURIA. 



255 



state of the vascular system, they cannot be objected to. But they 
are sometimes employed to express the cause of the dropsy, as if this 
were the immediate consequence of the excitement or inflammatory 
condition. That such a condition is often present, is obvious not only 
from the febrile symptoms, but also from the buffy state of the blood 
when drawn from a vein, and from the dropsical effusions and fluxes 
being in many cases combined with both the symptoms and the pro- 
ducts of inflammation. Thus anasarca is often attended with great 
tenderness, and sometimes with an erysipelatous redness : swellings of 
the joints frequently have the character of rheumatic inflammation; 
effusion in the abdomen and pleura is commonly accompanied by pain 
or tenderness, and after death slight deposits of lymph are found in 
addition to the serum ; catarrhal flux from the bronchi, and diarrhoea, 
are associated with more irritation (spasm, constriction, and cough, or 
vomiting, pain, and soreness) than occurs with simple fluxes. 

But this inflammatory character may be readily explained by refer- 
ring it to the irritating quality of the excrementitious matter which 
the imperfect action of the kidneys leaves in the blood. In this form 
of dropsy, urea has been found in the blood and in various effusions 
(§ 170,) and may therefore be fairly regarded as a materies morbi^ 
carrying irritation to various parts, and setting up excitement and sun- 
dry effusions or discharges, as the system seeks to relieve itself from 
its offensive presence. In two points this condition resembles acute 
rheumatism (§ 351 ;) — 1. in the number of distinct organs which may 
be simultaneously or successively affected ; 2. in the want of any con- 
stancy in the seat of the affections. Both these circumstances indicate 
that the essential cause is not in the disordered part, but in the blood. 
Another peculiarity which approximates these morbid states to gout 
and rheumatism, is the nature of the excrementitious matter which 
accumulates in the blood. There is good evidence that lithic and lac- 
tic acids are the chief abnormal ingredients that are present in gout 
and rheumatism (§ 256 ; ) but I have so commonly found also an excess 
of urea in the urine of patients recovering from rheumatism, and the 
most effectual remedies for gout and rheumatism so distinctly increase 
the elimination of this principle (§ 257,) that we can scarcely doubt 
that in these affections urea also is either produced in excess, or is in- 
sufficiently excreted. The proximity in composition between lithic acid 
and urea, and the probable conversion of the former into the latter 
(Liebig,) should be borne in mind while considering this subject. Both 
gout and rheumatism, as well as oliguria, frequently produce fluxes or 
catarrhal affections. Indeed the periodic recurrence of catarrh in cer- 
tain individuals bears a strong resemblance to the analogous visitations 
of gout; and they are sometimes vicarious in the same subjects. Last- 
ly, the relation of these affections to imperfect purification of the blood, 
is further illustrated by the facts, that rheumatism is frequently com- 
plicated with albuminuria (as after scarlatina ;) and that granular 
degeneration of the kidneys (Bright's disease) is apt to supervene in 
the most aggravated forms of rheumatism. 

386. But besides the retention of excrementitious matter in the 
blood, there is also in these cases a loss of albumen from this fluid. 



256 



RESULTS OP HYPEREMIA. 



That this loss facilitates dropsical and profluvial effusions, by thinning 
the blood (§ 383,) is most probable in all instances: but it seems to be 
the especial cause of the same results in the more chronic forms of dis- 
order, and in the most anremic subjects ; for here (as it has been alrea- 
dy stated (§ 264,) the blood is thinner and more watery than it is in 
any other disease. Thus in advanced stages of granular degeneration 
of the kidneys, and even in earlier stages if the subjects are anaemic, 
almost every congestion or determination of blood ends in watery ef- 
fusion. As the powers of the circulation fail, gravitative congestion 
chiefly determines the situation of the effusion, and hence it mostly 
occurs in the lower extremities, and the oedema presents in a marked 
degree the property of pitting on pressure, and very readily draining 
through any punctures made in the skin ; in this respect differing from 
the dropsy of acute albuminuria, in which the swelling also affects the 
face, the trunk, and the upper extremities, the pitting not being always 
distinct. The former dropsy is well entitled to the appellation — asthe- 
nic or passive, both on account of its being connected with congestion 
and weakness of the circulation, and from the poor condition of the 
blood, and the consequent depressed or cachectic state of the vital 
functions dependent upon it (§ 262, 185.) 

387. From the preceding statements it will be inferred that acute 
dropsy arises chiefly from the retention in the blood of excrementi- 
tious matter and water which the kidneys fail to eliminate, and that 
the more chronic or asthenic kinds of the disorder, although often 
originating in the same way, are rather dependent on a poor watery 
state of the blood, especially deficient in albumen (§ 222.) This defi- 
ciency in many cases arises, both from the continued drain by serum 
in the urine and from the imperfect assimilation and nutrition connect- 
ed with the state. But there is sufficient evidence that the more 
chronic and asthenic forms of dropsy do sometimes arise from this 
impoverished state of the blood, independently of disease of the kid- 
neys. Thus Andral and Delafond found dropsy to occur in anaemic 
sheep in connexion with distomata in the liver, only when the albumen 
of the blood was below the natural standard. The dropsy induced in 
the human subject by very scanty or poor food, by close confinement in 
unhealthy places, or by residence in malarious districts, and that super- 
vening in extreme states of debility or cachexia, are probably depen- 
dent, not merely on weak or obstructed circulation, but also on an 
impoverished condition of the blood itself. For the same reason, 
the various structural diseases which cause congestions, especially those 
of the heart and liver, often do not induce dropsy until the quality of 
the blood is impaired through imperfect excretion and inadequate nu- 
trition. 

888. We have thus traced the origin of flux and dropsy in common, 
to states that have been previously considered by themselves, — hyper- 
emia in some of its forms, and a diseased condition of the blood (§ 222.) 
dependent on defective excretion (§ 249, 250,) or defective nutrition or 
assimilation (§ 268.) The latter element, although not essential to the 
production of fluxes or local dropsies, is the main cause of general 
dropsy, and is at the bottom of what is called the dropsical diathesis. 



FLUX AND DROPSY — TREATMENT. 



257 



If beyond this we endeavour to distinguish between the pathological 
causes of flux and dropsy, observation will teach us that flux more com- 
monly results from determination of blood or congestion, with a lax 
state of the solids (§ 123, 382,) and that dropsy is associated rather 
with the altered condition of the blood. 

389. The distinction thus made between the causes of flux and drop- 
sy implies that flux is generally a more local affection than dropsy, for 
many circumstances relax the vessels of a part without affecting the 
condition of the blood in the whole system. This is especially apt to 
happen to secreting organs and surfaces, and hence these are the com- 
mon seat of fluxes. Excessive secretion has been already noticed as a 
primary element of disease (§ 162,) but the fluxes now under consider- 
ation consist less in excess of the natural secretion (although this 
often occurs also,) than in the addition to it of a watery, saline, and 
sometimes albuminous fluid derived from the blood, a serosity in fact 
(§ 305, 375.) The fluids discharged in coryza, bronchorrhcea, gastror- 
rhcea, and watery diarrhoea, consist of the natural mucus of the re- 
spective surfaces, much diluted with a thin serum, the saline matter of 
which often gives to the secretion an irritating property. Sometimes 
this serous fluid is completely substituted for the proper secretion, as 
in the- ooagulabie urine of the more advanced stages of Bright's disease. 

The circumstances which most commonly induce flux in secreting 
surfaces have been enumerated (§ 376, et seq.,) but after a flux has 
continued for some time, it is apt to become habitual, apparently in 
consequence of the permanent relaxation of the affected vessels. 
These become so weak that any circumstance which disorders the cir- 
culation brings on an attack of the flux. In fact, the flux becomes an ha- 
bitual cutlet for superfluous fluid thrown into the blood-vessels, and 
the ordinary escape for discharges which ought to be evacuated through 
the kidneys, skin, or bowels. 

GENERAL TREATMENT OE ELUX AND DROPSY. 

390. As there is so much that is common to fluxes and dropsies, our 
notice of remedial measures may be advantageously arranged by first 
alluding to the treatment that is equally applicable to both, and by 
afterwards specifying that which is more particularly suited to each. 

In so far as fluxes and dropsies depend on plethora, sthenic or asthe- 
nic, on congestion in any of its varieties, or on determination of blood, 
the remedies for these several morbid states (§ 283, et seq.. 313, et seq. y 
342, et seq.) must form part of the treatment. So, also, as according 
to the prevalence of these constituent conditions, fluxes or dropsies 
may be more or less sthenic and active, or asthenic and passive, and 
more or less constitutional or local, the treatment must be varied cor- 
respondingly. And again, as these conditions are tractable or not, the 
fluxes and dropsies resulting from them may be easy or difficult to re- 
move, and may exhibit great variations in regard to duration and dis- 
position to return. Thus fluxes and dropsies which arise from conges, 
tions caused by structural disease of the heart or liver, or by the 
pressure of tumours upon veins (§ 375,) although often removed f 0 p a 
time ? are very likely to return ; whereas those that arise from cold 
17 



258 



RESULTS OP HYPEREMIA. 



(§ 378) weakness (§ 376,) previous excitement (§ 377,) or functional 
disorder, may, in many cases, be permanently cured. 

391. We have repeatedly stated the circumstances under which vas- 
cular congestion or fulness in itself suffices to induce dropsy and flux 
(§ 306, 383 ;) and under these circumstances the remedies for conges- 
tion and plethora are obviously of the first importance. Thus in dropsy 
or fluxes suddenly induced by structural disease of the heart and liver, 
often after exposure to cold, over-exertion or excitement, the condition 
of the blood has not materially suffered, and hence depletion, general 
or local, may then sometimes be advantageously premised before adopt- 
ing any other measures. Afterwards such other treatment should be 
employed as serves to reduce the remaining congestion and the effu- 
sions resulting from them, by the administration of remedies that in- 
crease the secretions; combinations of mercury, or antimony, with 
squill and digitalis, are peculiarly adapted to accomplish this object. 
Various other means contribute to the same end, in particular all such 
influences as are of an evacuant and derivative nature. Treatment of 
this kind approaches to the antiphlogistic, for we have already seen 
that the character and products of congestion of high tension, and of 
sthenic plethora, approximate to those of inflammation (§ 307.) In 
the more special causes of flux and dropsy however, — those that induce 
these results with slighter amounts of congestion or disordered circu- 
lation (§ 382) — those which constitute the dropsical and profluvial dia- 
thesis (§ 388) — we find conditions betokening general weakness, and 
requiring a tonic and more supporting plan of treatment; namely, a 
relaxed state of the solids, and a watery condition of the blood. But 
even in the management of these cases, it is sound practice to attempt 
to derive from the weak or congested parts, and to increase defective 
excretions. Further details on these matters will be better arranged* 
under the separate heads that follow. 

TREATMENT OP PLUXES. 

392. In all cases of flux, it is right to derive from the affected part, 
and to promote the natural excretions in other directions, by the em- 
ployment of some or other of the following means: warm bathing, warm 
clothing, exercise, friction and stimulant applications to the surface, 
the administration of diaphoretic, diuretic, and aperient medicines. 
It is also necessary that circumstances which promote congestion or 
determination of blood in the affected part, such as a dependent position, 
exp osure to heat, the application of cold elsewhere, too fluid a diet, &c, 
should be avoided. In addition to these measures, it may be requisite 
to use others that counteract or remove the irritations or obstructions 
which the flux itself causes. Demulcent and narcotic remedies are 
sometimes useful in this way in catarrh and diarrhoea, soothing the 
irritation caused by the secreted fluid; at other times, expectorants 
and purgatives are serviceable by promoting its expulsion. 

393. The further treatment of fluxes should be guided by the vas- 
cular state accordingly as it is sthenic or asthenic. Flux, like hemor- 
rhage, is sometimes attended by a hard, frequent pulse, heat of skin, 
and other signs of fever or of sthenic plethora : then evacuants, anti- 



FLUXES — TREATMENT. 



259 



monials, sedatives, and even blood-letting, are the remedial measures 
that are required. In fact, the disordered state borders on inflamma- 
tion, and needs a similar treatment. Some cases of flux of a sthenic 
character depend upon the presence of gouty or rheumatic matter in 
the blood: here colchicum and alkalies are the proper remedies, be- 
cause they promote the removal of this matter through the kidneys. 
Others, as we have seen, are connected with albuminuria (§ 380,) and 
are to be treated accordingly. In all these examples of sthenic or 
active flux, it is neither useful nor safe to attempt hastily to check the 
discharge by astringent remedies, lest the determination of blood that 
is present should end in a worse result, hemorrhage or inflammation. 

394. The majority of fluxes are, however, asthenic, and connected 
with a weak state of the vessels, local or general, and other plans must 
be adopted. Besides the general measures above alluded to (§ 392,) 
it is here safe and proper to endeavour to check the profuse exhala- 
tion, by astringents, stimulants, and general tonics. Astringent re- 
medies are most effectual when directly applied ; and the mode in which 
they then act, namely by constricting the relaxed vessels (§ 388,) is 
obvious. Thus acetate of lead, sulphate and acetate of zinc, sulphate 
of copper, nitrate of silver, alum, and the vegetable astringents con- 
taining tannic acid, are effectual in restraining leucorrhoea and diar- 
rhoea. Some of these remedies seem also to act through the medium 
of the circulation. Thus sugar of lead, sulphate and oxide of zinc, 
sulphate of copper, and mineral acids given internally, sometimes dis- 
tinctly diminish bronchial flux and profuse perspiration, as we have 
already seen that they arrest hemorrhage (§ 367.) Some fluxes are 
remarkably checked by medicines whose operation seems to be rather 
stimulant than astringent. Thus spices, essential oils, and brandy, 
sometimes cure pyrosis and diarrhoea ; cantharides diminish leucorrhoea ; 
cubebs and copaiba put an end to gonorrhoea ; balsams of copaiba and 
Peru occasionally check bronchorrhoea. It is uncertain how these re- 
medies operate ; but as stimulants they most probably act by removing 
congestions, through causing determination of blood which excites con- 
traction and improved tone of the capillaries of the part (§ 317 :) hence 
they are certainly most successful in asthenic cases originating from 
inflammation. But many of them have a powerful diuretic operation, 
on which much of their efficacy may depend: and some seem to exert 
a peculiar influence on the secreting powers of mucous membranes. 
Another medicine occasionally useful in controlling fluxes, is opium; 
its mode of action is not obvious ; but is probably connected with its 
power to diminish natural secretions (§ 166.) Its eflicacy is most ap- 
parent in diarrhoea and diuresis: but it is sometimes beneficially com- 
bined with metallic astringents in the treatment of bronchial and gas- 
tric fluxes. 

The state of the system in persons subject to fluxes is generally one 
of relaxation, and is therefore benefited by tonic medicines. Such of 
these as have also an astringent property, are peculiarly adapted to 
prove serviceable in asthenic fluxes. It is thus that the tincture of 
the sesquichloride of iron is useful in the treatment of leucorrhoea and 
humoral asthma, attended with much debility ; infusion of cusparia, in 



« 



260 



RESULTS OP HYPEREMIA. 



that of diarrhoea; and bark or quinine with mineral acids, or gallic 
acid and tannin, in most of the profluvial disorders of very relaxed 
habits. 

For the same reason the diet should be as generous as the digestive 
organs will bear; including the use of animal food twice a-day, if prac- 
ticable, and a moderate allowance of some sound fermented liquor. 
Excess in liquid food should be particularly avoided, especially large 
quantities of tea, and warm slops generally. I am in the constant 
habit of curing catarrhal colds, which are acute fluxes, simply by total 
abstinence from liquids during two or three days; and although this 
extent of dry regimen is obviously inapplicable to chronic cases, yet 
moderation in the use of liquids, especially before or during exposure 
to cold, is an important feature in the treatment even then. I have 
known several instances in which chronic coryza, bronchorrhcea, and 
diarrhoea were kept up, and possibly even brought on, by immoderate 
indulgence in drinking tea and other like beverages. These fluids 
cause a temporary fulness, which immediately finds a vent through the 
lax vessels of the weak part (§ 389.) The favourable influence to be 
expected from warm clothing, regular exercise, and a bracing, but not 
too cold, atmosphere is obvious from the previous considerations. 

TREATMENT OE DROPSY. 

895. In addition to the use of means requisite for the removal 
of that variety of hyperemia which induces the dropsy (§ 391,) the 
attempt must also be made to remedy, as far as possible, those condi- 
tions of the blood which have been found (§ 384) specially to favour 
the occurrence of the disorder. The chief and most prevalent c*ause 
which determines these conditions is a failure in the secreting powe? 
of the kidneys: its sign being a scantiness of the urine, a deficiency 
of the natural constituents of the excretion, sometimes with an acces- 
sion of albumen. The treatment of dropsy must therefore keep in 
view the condition of the kidneys, and the immediate cause of the fail- 
ure in their action, and also the state of blood which is the result of 
that failure. 

I have already several times pointed out (§ 309) reasons for sup- 
posing a highly congested state of the kidneys to be the first cause of 
that failure of their function which induces albuminuria and its conse- 
quences. The means that are found to be most successful in removing 
dropsy resulting from renal disease, correspond very well with this 
view. Thus in the acute or so-called inflammatory dropsy that occurs 
after scarlatina or exposure to cold (§ 384,) blood-letting, especially by 
cupping the loins, hydragogue purgatives and diaphoretics, prove ad- 
vantageous at first ; and subsequently some kinds of diuretic medicine, 
particularly tincture^of cantharides, digitalis, and colchicum, tend to 
restore the natural- action of the kidneys. Such measures, if resorted 
to at an early period, and before the disease in the kidneys has af- 
fected their structure, are often completely successful. They fulfil, 
not only the indication of diminishing the renal congestion, but that 
also of purifying the blood from excrementitious matter, and of reducing 
the sundry effusions, local irritations, and disturbances, which this 



DROPSY — TREATMENT. 



261 



matter excites in various parts (§ 385.) They cure the dropsy by ex- 
citing artificial fluxes (§ 381.) 

Of the hydragogue purgatives used in the treatment of acute drop- 
sy, I have found cream of tartar in large doses (3iv. to 3x., every 
morning or every alternate morning,) gamboge (gr. iv. to viii.,) and ex- 
tract of elaterium (J gr.,) to be the most effectual. Tartarized antimony, 
alone or combined with opium, is the best diaphoretic, and it often re- 
lieves the catarrhal symptoms commonly present: but care must be 
taken that it do not cause vomiting, to which there is often a natural ten- 
dency. Dr. Osborne recommends the vapour bath, and Dr. Watson 
the hot-air bath, as measures likely to derive to the surface and to 
cause perspiration. After cupping to the loins has been repeated as 
often as the strength of the patient may allow, I have, in obstinate 
cases, seen much benefit follow the application of large blisters or 
other counter-irritants to the same part ; and in asthenic cases, which 
do not bear the loss of blood at all, very large blisters (a foot square 
and upwards) may be used at first with great advantage ; especially if 
followed by equally ample poultices. It is sometimes very remarka- 
ble how, on the rising of the blister, the urine increases in quantity, 
whilst its albumen diminishes ; and at this time diuretics, especially 
salines, act more favourably. 

Dropsical effusions are often soon dispersed by the preceding mea- 
sures ; but the proof of the permanent benefit of the treatment must 
be looked for in the progressive decrease of albumen, and the increase 
of urea and lithic acid in the urine. It sometimes happens that, after 
the full use of depletion, cathartics, and diaphoretics, the condition of 
the urine becomes stationary, and does not advance towards a healthy 
.standard. Then the diuretics already named may be very effectual in 
augmenting the quantity of urine, without increasing the albumen 
which it contains ; and where this is their first effect, steady perseve- 
rance in their use will often produce a gradual diminution of the al- 
bumen. The tincture of cantharides is more powerful than all the rest 
in exciting the action of the kidneys ; and where it increases the flow of 
urine, the dose may be augmented from irix. to itlxx. or 5ss. thrice a 
day ; but if the smaller dose does not act as a diuretic, it is not safe to 
proceed to the larger, nor, in fact, to persist with the medicine ; for it is 
then almost sure to irritate the kidneys, without increasing their secre- 
tion, and so to clo harm. Certain saline diuretics, as the acetate and 
bicarbonate of potass, the benzoate of ammonia, and the iodide of 
potassium, either separately, or better' in combination, sometimes suc- 
ceed where the stimulating diuretic fails^ A similar point has been 
alluded to in the treatment of congestion by stimulants (§ 317;) if the 
remedies fail to remove the congestion, they aggravate the mischief. 
Digitalis and colchicum are safer diuretics than cantharides, inasmuch 
as they are less irritating to the kidneys ; but they are also less pow- 
erful for good. 

Mercury might be expected to be a useful agent in the removal 
of congestion or low inflammation from the kidney, and in the resto- 
ration of its secretion ; but it salivates so speedily and severe- 
ly in many cases, that it is not generally eligible, except in an 

, .0 



262 RESULTS OF HYPERxEMIA. 

occasional dose. The promptitude with which the gums are affected 
with mercury may be ascribed, partly to the facility with which inflam- 
mation is excited in any and every part (§ 385;) and in some mea- 
sure, also, to the failing action of the emunctories of the system, which 
permits the mineral to accumulate in the blood more speedily than 
usual (§ 260.) As a practical rule, I have found that mercury is well 
borne, and is often useful, in those cases of albuminuria in which there 
is a deposit of urates or of free uric acid (which deposit denotes con- 
siderable secreting power in the organ,) and that it is injurious and 
salivates quickly where the urine is pale and alkaline or neutral. Mer- 
cury is peculiarly efficacious in dropsy connected with diseased liver: 
and with squill, digitalis, and henbane, or conium, it forms a most use- 
ful diuretic combination in all recent cases of the disorders that are 
dependent on congestion, 'without actual disease of the kidneys being 
present. Here also the urine is highly loaded with lithates and co- 
louring matter. 

396. It has been stated (§ 386, 387) that the asthenic forms of 
dropsy, and those of the most chronic character, are commonly con- 
nected with a watery, non- albuminous state of the blood, and general 
weakness of the system. To obviate this condition, so far as possible, 
by nourishing diet, tonics, and such management as increases the 
strength, becomes in such cases an important indication. When the 
disorder depends on mal-nutrition or mere debility (§ 387,) this tonic 
and supporting treatment may be sufficient to effect a cure. In the 
more common examples of dropsy, rendered asthenic by the long con- 
tinuance of structural disease of the kidneys, liver, or other organs, the 
same strengthening and invigorating measures must be more or- less 
combined with the employment of agents calculated to excite the fail- 
ing excernent organs, or to produce some compensating discharge. 
Thus in dropsy from chronic albuminuria, and advanced stages of 
granular degeneration of the kidney, the occasional exhibition of hy- 
dragogue purgatives and diaphoretics, and of the diuretics mentioned 
above, may prove advantageous, if bitters with iodide of potassium, 
or mineral acids, are given at the same time to keep up the general 
strength and powers of nutrition. In the more anemic cases, iron is 
often of service ; but it sometimes proves injurious by impairing the 
little secreting power remaining in the kidneys, and then rendering 
the urine more albuminous. Where it has this effect, its use must be 
abandoned. The preparations of iron that I have found most service- 
able under appropriate circumstances are the ammonio-citrate combined 
with iodide of potassium, and the muriated tincture. Gallic and tan- 
nic acids have likewise been recommended under similar circumstances. 

Asthenic dropsy arising from diseased liver is sometimes signally 
relieved by the combined influences of mercurial and diuretic medi- 
cines, followed by, or even conjoined with the administration of calum- 
bo, bark, and other vegetable tonics. In several cases I have succeed- 
ed in removing ascites, of great extent and long duration, connected 
with granular degeneration (cirrhosis) of the liver, by a course of 
hydragogue doses of cream of tartar every morning, or every other 
morning, with the use of iron, bark, or quinine, and nourishing diet in 



DROPSY — TREATMENT. 



263 



the clay ; and the patients have seemed for the time to be restored to 
health. Hydragogue purgatives are the more directly useful in re- 
moving ascites connected with diseased liver, inasmuch as they excite a 
discharge from the congested vessels themselves, and so substitute ab- 
dominal flux for abdominal dropsy (§ 381.) But they often fail to 
excite a watery discharge from the intestines, and cause instead much 
irritation and tenesmus, with slimy or bloody stools : under these cir- 
cumstances their use must be discontinued ; but after blistering the 
abdomen, or applying leeches to the region of the liver, or to the anus 
(§ 319,) and substituting a gentler but more searching aperient contain- 
ing mercury, the useful operation of hydragogue purgatives may 
sometimes be again obtained. Similar means will often facilitate the 
operation of diuretics. Dr. O'Beirne has argued strongly in favour 
of blood-letting in dropsy, under the impression that, by relieving the 
pressure upon congested vessels, it enables secreting organs to resume 
their activity (Dublin Journ. of Med. Sc., Nov. 1842.) But like most 
other writers on dropsy, Dr. O'Beirne does not, as it seems to me, suffi- 
ciently regard the mixed character of the disease. 

397. The unquestionable tendency which dropsy connected with 
diseased heart, kidneys, or liver, has to recur again and again, and to 
become chronic, renders it essential that the remedies employed should 
be varied as much as possible, as well as that the strength should be 
supported by all available means. It is an important point in the 
treatment of such cases not to exhaust the powers of any secreting 
organ by too long acting on it, and not to expend the efficacy of any 
one remedy by too long continuing its use. By employing, sometimes 
diuretics, sometimes purgatives, and sometimes diaphoretics, and by 
aiding each by local depletion, or by derivation, or by the administra- 
tion of stimulants and tonics, according to the temporary prevalence 
of vascular fulness and excitement, or the converse, life may often be 
considerably prolonged. It is in the application of these rules to the 
treatment of protracted cases, that the skill and resources of the ra- 
tional practitioner are the most tried, and his superiority over the mere 
routinist the most strikingly exhibited. These considerations point 
out why it is well to have at command a great variety of medicines, 
particularly of diuretics, and to alternate them with each other, or vary 
them, with a view to the increase or maintenance of their effect. There 
are in fact several great emunctory paths through which the blood con- 
stituents are mainly conveyed from the system, and medical art pos- 
sesses influences by which it can at will increase the flow by any or all 
of these. The true eliminant medicines enter the blood, and then pass 
out from it through the secernent organs, stimulating and augmenting 
their activity as they do so. But some address themselves more to 
one organ, and some to another. All, however, drain away water, this 
being the great carrying agent in all the vital processes. Of the five 
grand emunctory organs, three are chiefly devoted to the task of re- 
moving the three principal organic or constructive elements — carbon, 
hydrogen, and nitrogen. The lungs exhale the carbon as carbonic 
acid. The liver disposes of the hydrogen by converting it into fat and 
sugar; and the kidneys pour out the nitrogen in solution. The skin 



264 



RESULTS OF HYPEREMIA. 



and the glands of the intestines act as auxiliaries to the lungs, the liver, 
and the kidneys. So that when it is desired to get rid of any fluid 
deposit, morbidly thrown down as a dropsy within the system, the ef- 
fect may be produced by draining off the water of the blood through 
any of these several paths, by placing in the circulation medicinal agents 
that have no natural right to be there, and therefore will be expelled 
in solution. The exhausted blood then takes up the effused liquid to 
keep itself duly supplied with moisture. It is peculiar to the action of 
mercury that it increases the eliminant action of all the several excre- 
ting organs; all of them take part in the necessity of removing it from 
the blood. Hence the extensive range of its applicability whenever the 
system is in a state to support its impoverishing effect on the plastic 
constituents. I have often found combinations of mercury with squill, 
digitalis, and conium, of singular efficacy, when acute albuminuria is 
not absolutely present. But the greatest tact is generally required to 
detect the precise amount of congestive or structural change in the 
various sympathizing and correlated organs of the excretory appara- 
tus, in order that those may be stimulated to increased effort which 
are in the best state to bear the labour. It is an interesting fact, in 
illustration of the frequent connexion of liver disorder with renal dis- 
ease, that when the urine is laden with albumen, oil globules and fatty 
matter may often be detected by the microscope adhering to the shed 
epithelial scales. If, under such circumstances, blood be taken from the 
arm, the serum, after separation from the clot, is found to be quite milky 
from the presence of oil globules, which may be dissolved out by 
digestion in ether (see Dr. J. F. Duncan, in the Dublin Medical Press, 
June 28th, 1848.) All this points to the probable close relation be- 
tween albuminuria and fatty degeneration. It is in cases of this de- 
scription that some beneficial result may be hoped for from the hydra- 
gogue powers of elaterium, through which the various effete matters 
that can no longer escape either by the kidneys or the liver, may be 
drained away from the large excernent surface of the intestines, esti- 
mated at no less than 1400 square inches in the adult frame. There 
is here, on the other hand, very little chance that any good effect can 
attend the employment of saline and stimulant diuretics. But elateri- 
um, that may thus prove so serviceable when administered at the right 
time, is an agent of the most dangerous kind if unadvisedly given. In 
dropsy supervening on cardiac obstruction, a full dose of elaterium is 
very apt to increase the effusion by still further debilitating the alrea- 
dy weakened organ. It is in these cardiac cases that the diuretic 
treatment wears the most promising aspect. Such forms of the reme- 
dies answer best, as tend merely to diminish the water of the blood, 
rather than to eliminate its more solid constituents, and the dose should 
not be much diluted with water, or it will perchance take with it as 
much liquid as it causes to be carried away. Small doses of the ni- 
trate or acetate of potash, in strong decoction of broom or pyrola um- 
bellata, will often effect what is desired. I may also add, that among 
the various combinations that have proved serviceable in my hands in 
different forms of disorder, I may name the following :— iodide of po- 
tassium and bitartrate of potash, given with infusion or tincture of 



DROPSY — TREATMENT. 



265 



digitalis, in the dropsy consequent on scarlatina : nitrate and acetate 
or bitartrate of potash, or nitric acid, with juice or extract of taraxa- 
cum, where there is hepatic affection: iodide of potassium, bitartrate 
of potash, digitalis, and increasing doses of cantharides, in some kinds 
of acute albuminuria, after cupping the loins and administering hydra- 
gogue purgatives: ammonio-tartrate and ammonio-citrate of iron in 
seltzer water, in the more ordinary asthenic states; gin, in ii iperial 
drink (cream of tartar beverage,) compound spirit of juniper, spirit of 
nitric ether, and other stimulant diuretics under various conditions of 
debility. But this last class of remedies has disappointed me more 
frequently than any of the rest. 

398. When dropsical swellings have reached a certain amount of 
tension, medicines produce little or no effect on them. The veins and 
lymphatics, whose office it is to remove the effused fluids, are too much 
compressed to be capable of absorbing. In the case of ascites, the 
pressure of the accumulated liquid impedes the circulation through the 
kidneys and intestines, and their secretions are proportionally reduced 
(§ 159.) Extensive hydrothorax, and even ascites, embarrass the func- 
tions of the lungs and heart in a similar way. Anasarca, in its extreme 
degrees, sometimes hinders the circulation in the vessels of the lower 
extremities, so far as not only to prevent absorption, but even to 
cause the death of the parts : hence gangrene of the legs is a common 
termination of incurable dropsy. The gangrene is commonly pre- 
ceded by an erysipelatous kind of inflammation, which seems to origi- 
nate either in some accidental scratch, or from the irritation of me- 
chanical tension, or of the quality of the effused fluid. 

• JSTow, in all these cases, the great expedient is to remove a portion 
of the effused fluid, by tapping or puncturing the parts which contain 
it. Thus the abdomen is tapped for ascites ; the chest for hydrothorax ; 
the scrotum for hydrocele ; the brain for hydrocephalus ; ovarian and 
other cysts, when they become dropsical to a great extent; and the 
legs are acupunctured for anasarca. The relief afforded by these 
means is often very remarkable, even when a great deal of the fluid 
is still left behind. In fact, the main utility of these operations seems 
to consist in the relief of such amount of pressure and distention as 
seriously impedes the functions of the neighbouring organs. Ac- 
cordingly, after their performance, not only is a great mitigation of 
suffering experienced, but also a restoration of the functions of cir- 
culation, secretion, respiration, &c, which had been mechanically ob- 
structed. M. Lombard has shown that ascites which resists the or- 
dinary treatment, will sometimes disappear after the accompanying 
anasarca has been removed by puncturing the skin. After paracen- 
tesis, diuretic and other remedies which had lost their power, become 
again useful, and contribute their aid to reduce the remaining effusion ; 
and the secretions being free, the patient is able to bear nourishing 
food and strengthening remedies, which previously would have increased 
the excitement and oppression. 

The usual indication that requires the use of these surgical resources 
is, an amount of dropsical effusion sufficient to seriously injure the 
functions of circulation, secretion, or respiration, other remedies having 
failed to give relief. Under such circumstances the operation should 



266 LOCAL HYPEREMIA — INFLAMMATION. 

not be delayed. In puncturing the legs for anasarca, it is proper to 
bear in mind the tendency to low inflammation and gangrene ; the skin 
and flesh should on this account be injured as little as possible; nu- 
merous punctures should be made with a fine needle, but not too close 
together ; and as there is more tendency to the production of this un- 
desirable result where the circulation is weakest and most remote from 
the heart, it is better to puncture more above than below the knees. 

After the removal of dropsical effusion by operation or otherwise, its 
recurrence may in some cases be prevented by the influence of pressure, 
skilfully maintained on the affected parts by aid of elastic bandages or 
belts, to which in some instances elastic air pads, made of vulcanized 
India-rubber, may be added to increase the pressure in a given direc- 
tion. These expedients have certainly proved serviceable in several 
examples of ascites, ovarian dropsy, and anasarca ; in retarding or even 
preventing the reaccumulation of fluid. They act by giving support to 
weak vessels, and preventing the congestions which precede effusion. 
Another remedial measure, adapted only to certain forms of saccular 
dropsy, is the injection of a solution of iodine into the sac. It ap- 
pears from repeated trials in France and in this country, that a solu- 
tion of iodine, considerably stronger than that of the pharmacopoeia, 
may be introduced into the sac of hydrocele and of ovarian tumours, and 
even of the peritoneum, and in dropsy of the joints, without injurious 
results ; and with the effect of more or less preventing the return of 
the effusion. The remedy certainly deserves farther trials, not in such 
cases only, but also in serous and purulent effusions into the pleura. 

Farther details on these subjects properly belong to special patho- 
logy, and would be out of place here. 



SECTION VII. 

LOCAL HYPEREMIA. EXCESS OF BLOOD IN A PART. 

III. WITH MOTION PARTIALLY INCREASED, AND PARTIALLY DIMINISHED^ 

INFLAMMATION. 
DEFINITIONS. 

399. The morbid conditions connected with quantity and motion of 
the blood, hitherto described, have been pretty distinctly defined ; and 
we have been able to refer many phenomena of disease to them. We 
now come to another of the same class, the name of which is very fa- 
miliar, and whose frequent occurrence gives it so high an importance, 
that it has always attracted great attention amongst pathologists; but 
although so commonly occurring, this condition is of a much more com- 
plicated nature than any of the morbid elements previously considered ; 
in .fact, it may be said almost to comprehend them all, besides being a 
still farther deviation from the natural condition. 



DEFINITIONS. 



267 



The terms inflammation, phlegmasia, and phlogosis, have been used, 
from a very remote period, to denote collectively the heat, redness, 
burning, and painful sensations which commonly exist in inflamed 
parts. These symptoms are so frequently seen, and have hence be- 
come so familiar, that inflammation has long been distinguished as a 
chief element of disease ; in fact, it has, in a measure, engrossed the 
attention of pathologists so exclusively, that other important elements 
have been almost overlooked; and this oversight has not only retarded 
the advancement of our knowledge with regard to these other elements, 
but it has also rendered the subject of inflammation itself less intelli- 
gible, by excluding the consideration of some of its component parts, 
and by keeping it in its complexity and remoteness from the normal 
conditions of function and structure. It will be found, that an ac- 
quaintance with the ultimate and proximate elements of disease, already 
considered in this work, is essential to the proper comprehension of 
the nature of inflammation ; for these form the connecting link between 
the natural properties of living textures, and the extreme of departure 
therefrom, which is presented in this state. The pathological defini- 
tion given above, to distinguish inflammation from the other varieties 
of hyperemia — too much blood in a part, with motion (of that blood) 
partially increased, partially diminished — is illustrated in the strong 
pulsation of arteries leading to an inflamed structure, and in the 
stagnation of much blood in the structure. 

400. But in addition to this pathological definition, the outward 
character of inflammation may also be briefly defined by the four signs 
which, from the time of Celsus, have been considered distinctive of its 
presence, namely, redness, heat, pain, and swelling. These symptoms 
are, it is true, sometimes produced by congestion (§ 303.) and by de- 
termination of blood (§ 333, &c. ;) but in a degree less marked, and for 
a time less continued, than in inflammation ; and although there are 
cases and forms of inflammation in which it is not possible to detect 
all these marks, they may still be said to constitute its most general 
character. In common with other varieties of local hyperemia, in- 
flammation owes the production of redness to the excess of blood in 
the part, but we shall find that this redness is heightened by a peculiar 
concentration of the blood corpuscles in the inflamed vessels, and that 
this is also the cause of some of the peculiar results of the process. As 
in determination of blood, the heat and pain are in part due to the in- 
creased motion of the blood ; but they are exaggerated by the motion 
being opposed to obstruction. As with other forms of hyperemia, the 
swelling arises partly from the over-distention of the blood-vessels, and 
partly from effusions from them ; but these effusions in inflammation 
differ from those of congestion and simple determination, for they de- 
part still farther from natural quantity and quality. 

CAUSES OF INFLAMMATION, AND THEIR MODE OF OPERATION. 

401. Predisposition to inflammation has been already noticed under 
the head "predisposing causes of disease" (chap. i. sect. 2.) The cir- 
cumstances which render the body liable to inflammation are those 
which especially affect the vascular system, whether these circumstances 



268 



INFLAMMATION. 



be the result of original conformation, as the sanguine temperament 
(§ 38 ;) or whether they be the effect of previous disease (§ 31,) of pre- 
sent disease (§ 34,) or of external or internal causes in actual opera- 
tion (§ 20, et seq. 30.) Inasmuch as various circumstances, external 
or internal, tend generally or locally to impair the healthy tone and 
balance of the vascular system (§ 123,) whilst muscular irritability 
(§ 112) and the quantity of the blood are not proportionately reduced 
(§ 195,) they so far predispose to inflammation. Accordingly, we find 
persons prone to inflammation to be those whose circulation has been 
weakened or irregularly excited by previous disease, fatigue, confine- 
ment, impure air, or improper nourishment. But it will presently ap- 
pear that the predisposition differs according to the nature of the cause 
which excites inflammation ; those who are most subject to it from 
causes acting generally, suffering less than others from causes which 
act only locally. Thus a depressed state of the whole vascular system 
favours the production of inflammation by causes acting generally (such 
as cold ;) whereas an excited state of the vascular system favours the 
development of inflammation from local irritation. 

402. The concluding passage of the last paragraph prepares us to 
divide the exciting causes of inflammation into those which act locally 
on the part which inflames, and those which act more generally on 
other parts. The operation of the first class is direct ; that of the 
second is indirect, and therefore less certain, and more dependent on 
predisposition. 

The local exciting causes of inflammation comprehend irritants, 
whether mechanical, chemical, or vital. A grain of sand in the eye, 
a thorn in the true skin, and a bruise or wound in the flesh, are exam- 
ples of mechanical irritants, acting as sources of irritation. Chemical 
irritants are such agents as operate on living matter by strong chemi- 
cal affinity, and tend to alter or decompose it (§ 53 ;) heat, strong acids 
and alkalies, various corrosive salts, chlorine, and iodine, are of this 
kind: such act in like manner on dead textures. Vital irritants are 
various agents, which produce no effect on dead animal textures, and 
whose irritating operation is not referable to any known chemical pro- 
perty ; of this kind are cantharides, mustard, capsicum, and essential 
oils. In this last class must also be included various animal and ve- 
getable irritant poisons, such as the matter of small-pox, and the ve- 
nom of some noxious animals and plants, which act as local irritants, 
besides otherwise affecting the system. Various noxious matters, ge- 
nerated in the living or recently dead body, are also capable of ex- 
citing inflammation when applied to an abraded surface (§ 258.) Nay, 
the natural excretions of the body themselves prove to be most acrid 
irritants, when brought into contact with serous and cellular mem- 
branes; thus urine, feces, and bile, if effused into serous membranes, 
even in the smallest quantities, produce intense irritation and inflam- 
mation. Frost-bite, or intense cold acting on a part, appears to per- 
manently injure the functions of living textures, so that the returning 
circulation establishes a process of inflammation in the parts less af- 
fected. 

Irritation and inflammation are sometimes caused by excrementitious 



CAUSES — EXCITING — IRRITANTS. 



269 



matter accumulated or retained in the blood in consequence of de- 
rangement of the functions of the excernent organs (§ 249, 251, 254.) 
Local inflammations are also excited by certain poisons received into 
the system: thus arsenic, even when applied to a wound, causes inflam- 
mation of the stomach and intestines ; mercury excites inflammation of 
the gums; phosphorus that of the bones of the jaws; the poisons of 
small-pox, scarlatina, and measles, inflame the skin, throat, and air- 
passages ; the poison of syphilis affects the periosteum, throat, skin, 
and iris in like manner. In these cases, there can be little doubt that 
inflammation is excited in the parts which inflame, by the actual pre- 
sence of the peculiar irritating matter, 1 conveyed there in the blood; 
and it is a frequent character in the operation of these irritants which 
are conveyed through the blood, that it affects several parts, or a con- 
siderable portion of the body at once; and frequently the two sides of 
the body in a similar manner. This is observed in the eruptions of 
exanthematous and other skin diseases, in rheumatism and gouty af- 
fections allied to it, in syphilitic nodes, &c. (§ 259.) 

It is highly probable that the presence of an irritating matter in the 
blood is a very frequent cause of inflammatiou, even in cases that are 
not considered specific. There is good reason for supposing that com- 
mon catarrhal inflammations are in some degree due to an influence of 
this kind, brought into operation by changes of the temperature or 
moisture, which disturb the balance of the circulation. This consti- 
tutes one predisposition to catarrhal affections, rendering a person 
liable to " catch cold," which consists in the development of a local 
inflammation by the joint operation of the change of temperature and 
of the peccant matter in the blood; and this matter being eliminated 
from the system during the inflammatory movement which follows, the 
system is left for awhile free from the predisposition. Thus may be 
explained the almost periodic return of catarrhs, to which many per- 
sons are subject, and which bears much analogy to the accessions of 
gout and other cumulative disorders. The same pathological principle 
is indicated also in the popular term, "heat in the blood," which not 
inaptly designates the peccant humour. 

403. The second class of causes exciting inflammation, those which 
operate indirectly, are of very common occurrence; and, although com- 
prising fewer agents, they as frequently produce diseases as the more 
direct causes. They include influences which first produce congestion, 
that is subsequently converted into inflammation on the occurrence of 
reaction. The most common of these is cold, which, both by its local 
operation (§ 76,) and by its more general application (§ 77,) may pro- 
duce congestions (§ 296, 292,) that ultimately pass into inflammation. 
Malaria and the poisons which induce continued and eruptive fevers, 
produce congestions (§ 293,) and thus often lay the foundation of in- 
flammation, which then complicates the febrile affections directly ex- 
cited by the same causes. Inflammations sometimes arise out of the 
congestions caused by venous obstruction (§ 289,) and mere gravita- 

1 The late Mr. Durance George showed me portions of the jaw-bone of a person who 
had taken mercury largely: globules of the metal were distinctly visible in the cancelhe 
of the alveolar processes. 

.# 



270 



INFLAMMATION. 



tion. Thus pneumonia (with hepatization and sometimes with suppu- 
ration,) frequently occurs in connexion with disease of the heart, that 
impedes the circulation; also in adynamic fevers, and in the sinking 
which precedes death (§ 290.) The congestions of blood in the lungs, 
brain, and mucous membranes, that result from the application of va- 
rious asphyxiating causes (§ 298,) sometimes end in inflammations, 
which then become a chief source of danger after the restoration of 
the respiration (§ 235, 243.) 

404. Suppression of natural or habitual discharges, (especially the 
catamenial,) the sudden drying up of ulcers, and the repulsion of cu- 
taneous eruptions (§ 69,) are recognised causes of inflammation (§ 67.) 
When the inflammation excited by these causes is in, or contiguous to 
the parts previously affected, local irritation may have a share in pro- 
ducing it ; but when it is in distant parts, it probably results from a 
congestion or local determination of blood, which then belongs to the 
second class of causes just specified. Very probably some of these 
causes of inflammation have a two-fold operation, that just specified 
(producing a local fulness,) and that of local irritation by morbid mat- 
ters introduced into the circulating mass of blood. Thus the visceral 
inflammations arising on the sudden healing of a suppurating wound 
may be promoted by local congestions resulting from the cessation of 
the purulent discharge ; but their circumscribed character, and the uni- 
form event to which they tend (suppuration,) seem to indicate that the 
presence of a morbid matter in the circulating blood is their exciting 
cause, and microscopical researches have confirmed this inference. The 
same remark applies to the inflammations of the skin, fauces,, and mu- 
cous membranes that occur in scarlatina, measles, and small-pox; to 
the follicular enteritis of typhus, 1 and to the visceral complications of 
erysipelas, and other specific febrile affections. In all these, besides 
a general tendency to internal congestions, we seem to trace the irri- 
tating operation of a morbid poison on particular parts. 

405. We have noticed that sthenic hemorrhages (§ 363) and fluxes 
(§ 393,) if too speedily checked without sufficient reduction of the cir- 
culation, are apt to pass into inflammation. So likewise determina- 
tion of blood, if long continued, may issue in inflammation (§ 340.) 

1 I have observed an extraordinary enlargement and inflammation of the isolated and 
grouped glands of the intestines in the bodies of persons poisoned with arsenic. Their 
enlargement in epidemic cholera, and in the severe form of sporadic cholera, diarrhoea, 
and dysentery, caused by putrid effluvia, is well known. Are these glands excretory 
organs for the elimination of poisonous or noxious matters from the system? and in 
typhoid fever, do they become inflamed and ulcerated by the continued operation of the 
poison in the exercise of this function? The favourable influence of moderate diarrhoea 
in fever, the uncommon foetor of the stools, Ine general relation between the duration of 
the fever and the affection of these follicles, the salutary operation of mild mercurial 
remedies, which promote their secretion, and other facts that might be adduced, give so 
much countenance to this view as to make it worthy of attention. 

The preceding surmise, put forth in the first edition of this work (1843,) has received 
corroboration from numerous facts subsequently observed, and it seems to me to indicate 
the true cause of the intestinal complication in fevers and other diseases induced by a 
morbid poison in the system. Dr. Carpenter has recently advocated this opinion, and 
further applied it to account for the fetid and colliquative diarrhoea which often occurs 
in states of much depression (Human Physiology, 1853, p. 207.) 



CAUSES — NERVOUS INFLUENCE. 



271 



The causes which excite determination of blood when applied in a 
greater degree, or for a longer time, excite inflammation. 

406. Before we proceed to examine into the nature of inflammation, 
we may properly inquire what is the mode in which its causes operate. 
It has been generally assumed that the first movement of inflamma- 
tion, as of all other pathological processes, is to be found in the nerves-; * 
but this is by no means proved. That some causes of inflammation 
(irritants) operate first on the nerves, is probable from the following 
considerations. 1. Their action on the sensitive nerves is felt long 
before inflammation begins ; thus the prick of a thorn in the skin, the 
smarting of caustic on a wound, the pain of the sting of an insect, are 
felt instantaneously ; there is first nervous irritation ; inflammation 
follows after. The irritation is sometimes transferred to other parts by 
sympathy, of which nerves are the channels : thus strong irritants ap- 
plied to the nostrils may cause inflammation of the conjunctiva; the 
long-continued exertion of one eye in using the microscope, may induce 
inflammation in both eyes ; a calculus in the urethra may excite in- 
flammation in the testicle (Paget;)' a carious tooth or a diseased bone 
may irritate and inflame parts which are not contiguous to it. 3. An 
injury to a nerve is sometimes followed by inflammation in parts con- 
nected with this nerve. Thus paralyzed limbs are liable to become in- 
flamed. Lallemand relates a case in which a ligature, involving the 
right brachial plexus, was followed by inflammation and suppuration 
in the opposite hemisphere of the brain. 

407. On the other hand, the following arguments may be adduced 
to show that the cerebro-spinal nerves at least are not essentially the 
seat of the first stage of the process of inflammation. 1. Some of the 
causes of inflammation (the majority of those inducing internal inflam- 
mation) produce no known primary effect on the nerves or nervous 
system: thus inflammations excited by cold are often preceded by no 
marked nervous disturbance; and the strongest impressions of cold 
on the nervous system are frequently not followed by inflammation 
(§ 77.) 2. Inflammations often originate in congestions (§ 403) and 
in the sudden suppression of hemorrhages and other discharges (§ 405,) 
without the occurrence of any symptoms referable to the nerves : hence 
inflammations thus arising may escape detection, and are called latent. 
3. Persons in whom nervous properties are most developed (§ 126, 152, 
156,) are not the most susceptible of inflammation ; and all varieties of 
nervous excitement are sometimes manifest in the highest degree with- 
out any inflammation ensuing. Even where pain and other nervous 
symptoms are excessive, and are the result of mechanical or chemical 
injuries (such as crushed limbs, extensive burns, &c.,) inflammation 
sometimes does not follow ; and this has led surgeons long to distinguish 
between irritation and inflammation. 4. Inflammation is readily ex- 
cited in parts whose nerves are paralyzed, or have been divided : in 
fact, it sometimes occurs spontaneously in them. The experiments of 
Bernard seem to limit the influence of the nerves over the blood-vessels 
to the sympathetic system, in accordance with views previously held 
by Dr. Copland and others. But these experiments seem to prove that 
this nervous influence prevents inflammation instead of causing it. Thus 



272 



INFLAMMATION. 



when a branch of the sympathetic nerve is divided, the parts supplied 
by it spontaneously become the seat of determination of blood and 
subsequently of inflammation. It is plain therefore that an injury to 
the sympathetic nervous function may become a cause of inflammation: 
but it is by withdrawing nervous influence rather than by any positive 
operation. 

408. Seeing, then, that inflammation is frequently excited without 
any obvious affection of the nerves, and is often not excited when ner- 
vous irritation is most intense, it cannot be inferred that an impression 
on the nerves is an essential part of the process of inflammation. That 
the nerves are concerned in many of the phenomena of inflammation, 
and in its extension, is fully admitted: and in the case of excitement 
of inflammation by irritation, the primary operation of the exciting 
cause, even on the sensitive nerves, has been already pointed out 
(§ 406.) Possibly there may be a primary action on the sympathetic 
nerve or some of its branches which have an influence over the blood- 
vessels, but until this is made more evident by farther research it 
cannot profitably be dwelt on. So far as is known, the blood-vessels 
are the seat of the whole process of inflammation: and although some 
of the exciting causes of the state (§ 402, irritants) act on the nerves 
as well, yet others (§ 403, as cold) operate essentially only on the 
blood-vessels. TTe find that the causes predisposing to inflammation 
(§ 401) are circumstances chiefly affecting the vascular system. A re- 
view of the exciting causes of inflammation (§ 402, 405) will show* that 
in their mode of operation on the blood-vessels they may be divided 
into two classes: 1, those that cause determination of blood (§ 322 — 
S24 :) and, 2, those that produce congestion (§ 290 — 299.) The former 
class comprehends all irritants (§ 402 ;) the latter class includes cold 
and other agents which directly produce congestion (§ 403, 405.) TTe 
have several times had occasion to mention that determination of blood, 
when exceeding certain limits, is apt to pass into inflammation (§ 840;) 
and that local congestions are liable to be converted into inflammation 
(§ 292, 293, 306.) 

PHENOMENA AND NATURE OF INFLAMMATION. 

409. Having: noticed the causes of inflammation, and traced their 
essential operation to the blood-vessels and their contents, we have next 
to inquire what the character of that operation on the vessels is, and 
what the phenomena are that it develops. 

That the blood-vessels are enlarged in an inflamed part might be 
inferred from the increased redness manifest to the naked eye. But 
in what respect does inflammation differ from congestion, in which also 
the vessels are enlarged? It differs not only in the accompanying 
symptoms, and in its results, but also in the observed condition of the 
vessels of the part. Thus, besides greater pain and heat, and earlier 
and more abundant effusions, the more florid hue of the redness, the 
strong beating of the arteries leading to the part, and the augmented 
quantity of blood flowing from its veins, clearly indicate that there is 
increased motion of blood, instead of diminished motion, as in conges- 
tion (§ 287.) 



PHENOMENA AND NATURE. 



273 



Casual observation of the pulsation of arteries leading to inflamed 
parts, suffices to show that there is determination of blood to them ; 
and some experiments performed by Dr. Alison and others have also 
proved that these arteries are enlarged. 1 It was found that the arte- 
ries leading to the inflamed limb of a horse were considerably larger 
than those of a sound limb. John Hunter had arrived at a similar 
conclusion from experiments on the ears of a rabbit. Now this enlarge- 
ment has been traced to diminished tonicity in the affected arteries, a 
state which is the chief instrument in causing determination of blood 
(§ 326, 327.) 

That the motion of the blood is increased through an inflamed part, 
is distinctly proved by the observation of Mr. Lawrence ; venesection 
being performed at the same time, and in the same manner, in both 
arms of a patient who had an inflammation in one hand, a much greater 
quantity of blood flowed from the vein belonging to that hand, than 
from that of the other arm. 

410. It is certain, both from the preceding facts, and from direct 
observation by the microscope, that determination of blood is present 
in inflammation. The vessels in the vicinity of the inflamed part re- 
ceive an increased flow ; there is an augmented flux of blood towards 
the whole of it, and through some of its vessels. But if this were all, 
there would be no distinction between determination of blood and in- 
flammation : the greater redness and swelling, and the peculiar cha- 
racter of the effusion, however, point out that inflammation is not mere 
determination. Microscopic research has established one great point 
of difference. The observations of Thomson, Hastings, Kaltenbrunner, 
and Marshall Hall, have long clearly proved that there is more or less 
obstruction to the passage of the blood in the vessels most inflamed. 
Thus in the web of the frog's foot, when a part inflames from local 
irritation, the blood is seen to move more slowly where the irritation 
is greatest, and gradually accumulating in the vessels there, it renders 
them larger, redder, and more tortuous, until at length the motion 
ceases altogether in them, whilst neighbouring vessels are still per- 
meated by an increased current. A chief point then in which inflam- 
mation differs from determination of blood, is that there is retarded or 
arrested flow of blood in some of the vessels. This answers to the 
definition of inflammation already given : too much blood in a struc- 
ture, with motion (of that blood) partially increased, and partially di- 
minished (§ 399.) 

411. The question now naturally arises — What is the cause of the 
obstructed or retarded flow of blood through an inflamed structure? 
This has ever been the chief difficulty in the pathology of inflamma- 
tion ; and it is especially to solve this that various hypotheses have 
been framed. Thus Cullen supposed a spasm of the extreme vessels 
to be the cause of obstruction, and therefore the proximate cause (§ 13) 
of inflammation. Dr, Wilson Philip ascribes the same obstruction to 
a weakness of the capillaries which he presumes to incapacitate these 
vessels from transmitting the blood. John Hunter considered that 

1 Trans, of British Association, 1835. 

18 



274 



INFLAMMATION. 



there is something more active and vital in the enlargement of inflamed 
vessels, and he applied to it the term "active dilatation." The analo- 
gous expressions, "vital turgescence," " turgor vitalis," "inflammatory 
erection," used by Kaltenbrunner and other German writers, imply a 
similar notion. 

The hypothesis of Cullen is quite inconsistent with direct observa- 
tion, the extreme vessels being seen under the microscope to be in a 
state of dilatation, and not of spasmodic contraction. This observa- 
tion corresponds better with the idea of Dr. W. Philip, which was in- 
deed founded upon it: but it has been objected by Dr. Marshall Hall 
and others, that since the capillaries do not aid the circulation of the 
blood by their contraction, their "debility" cannot be a sufficient cause 
for interrupted passage of blood through them. The words used by 
Hunter scarcely convey any meaning that can be accepted as an ex- 
planation. They may be interpreted to assume the existence of a self- 
expansive power in the vessels, which power is supposed to act in in- 
flammation as well as in natural formative or plastic processes in the 
animal body. But the existence of such a power is quite at variance 
with all that is known of animal physics. A part may be expanded 
by elasticity, or by the injection or retention of fluid in it, but no direct 
vital expansile power has been ever proved to exist. The apparently 
active expansion of the heart, in its diastole, may be ascribed to the 
natural elasticity of the organ, and the increasing weight of its con- 
tents, suddenly enlarging its size on the cessation of its antagonizing 
systole: neither its structure nor its mode of action countenances the 
notion of a vital dilating power. 

412. Haller and some of his followers ascribed the circulation of the 
blood in part to certain supposed properties of vital attraction and re- 
pulsion, by which the blood is drawn into, or repelled from particular 
parts, independently of all motion of the living solids. These opinions 
have been recently advocated with much ability by Dr. Alison and 
others, who consider changes in these assumed vital attractions and re- 
pulsions to be the chief elements in the process of inflammation, as well 
as in other pathological conditions in which the blood and its vessels 
are mainly concerned. 1 This hypothesis needs the most ample proof 

1 See Alison's "Outlines of Pathology and Practice of Medicine," 1843, p. 122. Seve- 
ral of Dr. Alison's arguments in favour of the existence of "vital attractions and repul- 
sions" are founded on certain physiological facts, which he considers inexplicable in any 
other view. It belongs properly to works on physiology to discuss these matters ; but 
I would here express the opinion that none of these arguments seem to me to be satis- 
factory. The motion of the sap in the chara and other vegetables may be well explained 
on the principle of osmose and exosmose. A fluid of lower density (water) chemically 
acts on and penetrates membranous tubes, containing a liquid of greater density (sap:) 
that which begins a flow into the tubes, may sustain it in continued current through them 
so long as the difference in density and composition between the water and sap subsist. A 
similar principle doubtless aids the motion of fluids in the animal body in some instances ; 
in others the movements observed (as in the air tubes, genito -urinary passages, &c.) have 
been traced to the vibrations of cilia, and are therefore no proof of the existence of vital 
attractions and repulsions. 

It is said that when an artery is tied, the blood ceases to run in the open part of it, 
and passes away by adjoining branches, which become enlarged in proportion, whilst the 
tied portion becomes empty. It has been supposed that the blood here spontaneously 
leaves the part of the artery through which there is no passage. I demur to the correct- 



NATURE — ' 



OBSTRUCTION OF THE CAPILLARIES. 



275 



before it can be received. It assumes the existence, in the fluids as 
well as in the solids of the living body, of properties as distinctive and 
as peculiarly vital as that of contractility or sensibility. It ascribes 
to these fluids and solids powers of attraction and repulsion at sensible 
distances, like the attractions and repulsions of electricity, magnetism, 
or gravitation, yet distinct from all these, and sometimes opposed to 
them. It attributes to the living body a new physical power, and 
almost a discerning intelligence in the exercise of that power. Now, 
before the existence of such a power can be entertained, it must be 
proved that the phenomena under consideration are not, and cannot be, 
explained through any known vital or physical agencies. We have 
already adduced, and referred to, arguments and observations which 
tend to the view that the known physical and vital properties of the 
living body do account for the chief phenomena of health and disease, 
without assuming the existence of any forces of a mysterious character ; 
and we have now to consider whether the same thing is not the case 
with regard to inflammation. If we succeed in explaining the nature 
and effects of inflammation by a reference to ascertained properties, it 
will be needless and unphilosophical to assume the existence of others, 
which are mysterious and unknown. 

413. We have already stated (§ 408) that inflammation may origi- 
nate either in determination of blood, or in congestion; and we now 
proceed to show that it essentially comprises both these elements iri 
itself. The mode in which the process of inflammation has been chiefly 
studied, is by observing under the microscope the effect of irritants on 
the web of the frog's foot. It must be remembered, however, that this 
is only one mode in which inflammation may begin, and we shall here- 
after find that many of the lower vertebrate animals fail to exhibit 
some of the most remarkable results of inflammation. But observa- 

ness of the statement, and still more to the explanation. Every one who has witnessed 
great surgical operations must have noticed the strong pulsation above the ligature of 
tied arteries ; and the occasional occurrence of secondary hemorrhage shows that the 
blood has no inherent disposition to pass in a new direction. No doubt in time the ar- 
tery ceases to receive blood into its tied portion ; but this is because either a coagulum 
is formed where the current cannot pass, or the tonicity of this portion effects the con- 
traction of the tube, the force of the circulation being diverted into the contiguous en- 
larged branches. Here is no proof of any self-motory and self-directing power in the 
blood. I have before stated that all my own microscopic observations have failed to de- 
tect in the blood any spontaneous motions, independent of contractions of the solids or 
of currents caused by ciliary motion, osmosis and exosmosis, and such physical influences. 
The oscillatory motion said to have been seen by Haller and Kaltenbrunner in the small 
blood-vessels of inflamed parts, "even after the heart is at rest," may, perhaps, be 
ascribed to the tonic contraction of the arteries, which, although gradual in itself, is often 
seen to act by jerks on partially obstructed vessels. A similar oscillatory movement is 
sometimes communicated to capillary vessels by the quivering contraction of adjoining 
muscles. Another observation of Haller mentioned by Dr. Alison, that of "blood 
escaping from vessels between the layers of a living membrane, and nevertheless pursuing 
its course in a regular stream for a time, even against the influence of gravity," may be 
fairly referred to the vis & tergo from the open vessel. In the fluids of such a nicely 
adjusted hydraulic apparatus as the vascular system of animals, and even vegetables, it 
is surprising how readily motions may be produced by various physical causes; and 
when these motions are magnified by the microscope, it is not wonderful that they should 
have been mistaken for vital movements of the fluids themselves. It may be further 
added, that rhythmical contractions have been observed in some instances in the veins of 
lower animals ; as by Dr. M. Hall, in the tail of the eel, and by Mr. Wharton Jones, in 
the wing of the bat (Philosoph. Trans., 1852.) 



276 



INFLAMMATION. 



tions have also been made on the circulation in the wing of the bat, 
with very similar results. 

The effect of weak irritants on the vessels of the frog's web has been 
described before (§ 294, 326.) It was there stated that irritation may 
cause first determination of blood, and then congestion ; these results 
being dependent on an enlargement respectively of the arteries, and of 
the veins and capillaries. But if a strong irritant (as a grain of cap- 
sicum, or a minute globule of essential oil 1 ) be applied to the web, all 
its blood-vessels speedily become enlarged: those most irritated are 
very large and red, and the blood in them is stagnant and coagulated : 
contiguous vessels are also very large, but less red, and the motion of 
the blood in them is slow, and often in pulses or oscillations ; whilst 
in vessels beyond, the enlargement of the capillaries is less consider- 
able, but that of the arteries is obvious, and the current of the blood 
is very rapid. 

Now, it is obviously the stagnation or tardy motion, of blood in en- 
larged capillaries, in the midst of surrounding increased flow, that 
characterizes inflammation; we have, however, still to inquire what is 
the cause of the stagnation. This cause must be either in the vessels, or 
in their blood, or in both. The latter we shall find to be the true case. 

414. We have already pointed out (§ 300) that atony and flaccidity 
of blood-vessels may become a cause of impediment to a current through 
them, not by preventing these vessels from actively contracting on their 
contents, (for they have no such power,) but by removing that tone by 
which the vessels maintain the calibre and the tension best calculated 
to transmit onwards the force of the current. Vessels thus weak and 
inelastic, instead of equally conveying the current, become distended, 
lengthened, and tortuous on receiving it; and by the very mass of 
their contents, as well as by their inelasticity, they partly break the force 
of the current, and partly turn it into other channels. The mode in 
which this results in inflammation will be better understood, if we re- 
view other local modifications of the circulation in comparison with it. 

In determination of blood, the arteries are enlarged, and so are the 
capillaries in moderate proportion ; the circulation is therefore equally 
increased. In congestion, the capillaries are greatly enlarged, without 
any increase of the arteries : the motion is therefore impaired ; but still 
it may diffuse itself through the mass of the blood, which moves slowly. 
But if to congested capillaries there be added the increased and abrupt 
force of the current from enlarged arteries, or if to determination of 
blood (enlarged arteries, § 326) an atonic congestion of the capillaries 
be joined, the propulsive power of the current will be impaired. As in 
the experiment with the intestine (§ 300,) the blood will pulsate or 
oscillate in the distended vessels rather than pass through them; and 
the main current will pass through collateral anastomosing channels, 
which then become the seat of simple determination or increased flow. 
This is just the state of things in the incipient stage of inflammation ; 
and if either the capillaries do not speedily recover their tone, or 
the arteries do not contract, the blood becomes stagnant in parts, 

1 These are preferred because they produce no chemical change in the parts. 



CAUSE OF OBSTRUCTION. 277 

j particles adhere to each other, and to the walls of the vessel, and 
e obstruction is confirmed. Some of the capillaries still remain in 
&ir arterial portions open, and exposed to pulsative force from the 
£>plying arteries; which continues to strain their coats, and causes an 
oillatory motion of their contents, but no passage through them. 
$h are the phenomena which we see under the microscope. 

t may, then, be fairly inferred that one cause of the stagnation or 
rerdation of the motion of the blood in the inflamed part, is a weak, 
irHstic state of the capillary vessels ;* such, in fact, as exists in cases 
of onic congestion ; on referring to the causes of inflammation (§ 404,) 
it yi be perceived that many of them act by first producing conges- 
tion Nay, we have found (§ 294) that even irritants, in some measure, 
oper.e in the same way. " The continued application of stimuli to a 
part sometimes followed, not by inflammation, but by congestion. 
This specially happens in the liver, a chiefly venous organ ; but it 
occur&lso in other parts. It might be supposed that the stimuli act 
by existing the contractility of the small vessels, and thus leaving 
them Wakened and distended by their contents. . . ,m . 
But orthe application of a strong stimulant, such as a minute particle 
of essetial oil, the previous arterial contraction is not apparent, and 
the enhgement is speedy and obvious, causing extreme rapidity of 
motion *id enlargement in all the vessels. In a few minutes, the size 
of the aieries begins to diminish, and with it the motion in the capil- 
laries bejmd them. Many of the capillaries still retain their enlarged 
dimension ; in them the motion is most sluggish, and, in some parts, 
ceases altogether." 2 

415. Bu it is very certain that the obstruction and much of the 
other feati*3s of inflammation, are generally dependent on changes 
which take place in the blood within the inflamed vessels. J. Hunter 
did not overlook this ; and, besides describing the coagulation of the 
blood in the most inflamed vessels, he mentions the adhesion of fibrin 
to their interior. The coagulation of the blood in the inflamed vessels 
was also noiced by Gendrin and others; and Dr. Marshall Hall attri- 
buted the obstruction of the vessels in inflammation to the adhesion of 
blood-globules to the walls of the vessels. 

Poiseuille, in his observations with regard to the motionless layer of 
serum which intervenes between the moving blood and the walls of 
blood-vessels, had noticed that the blood corpuscles sometimes get into 
this still layer, and either remain fixed there, or move onwards more 

1 It may, perhaps, be objected that I have supposed a similar atonic state of the 
arteries to be the cause of an increased flow through them, and to be the physical cause 
of determination of blood. But this is no objection. The arteries, as compared with the 
capillaries, are few in number; the current in them is rapid; they are exposed to the 
pressure of a vis & tergo which maintains the velocity of that current, whatsoever may 
be their calibre: when their coats lose some of their tone, this pressure of blood into 
them stretches them to tension, and they thus admit an augmented force and volume. 
In capillaries, on the other hand, the current is so much subdivided and straitened that 
it is easily disturbed, and the motion, naturally tardy, is readily arrested, and this the 
more surely in proportion as the blood ceases to undergo the changes which naturally 
favour its passage through them (g 295, note.] 

2 Extracted from the author's Gulstonian Lectures for 1841: Medical Gaz., July 16, 
1811. 



278 



INFLAMMATION. 



slowly than the rest of the blood. In repeating this observation w' 
Mr. Toynbee, we remarked that it was not the red corpuscles, or e\lr 
tical blood discs, that thus adhered to, or slowly rolled along the sis 
of the vessels, but the white or colourless bodies (§ 212,) calledy 
Miiller, lymph globules. (The following description is taken from y 
Gulstonian Lectures, of 1841:) — "I have never seen a solitary elfai- 
cal disc adhering to the sides of a vessel; and whenever one wagtr- 
rested in its course, it w r as from its becoming hitched by one or ->re 
of the adherent round globules. But what appeared to me mosre- 
markable with regard to these white globules, was the great diffence 
in their number under diiferent circumstances. In young frogjand 
in those much subjected to experiment, they are always present inreat 
numbers ; but in healthy adult frogs, placed under the microscopwith 
as little handling of the web as possible, there were comparative few 
to be seen." It is under these circumstances that the effect of rota- 
tion or mechanical injury was best seen. "By pressure of thfinger 
on the web, partial stagnation w r as produced in many of theessels; 
and when this yielded to the returning current, the walls of ne ves- 
sels were seen studded with the white globules; whilst many <hers of 
the same kind rolled over them slowly in the direction of the^urrent. 
I have before mentioned (§ 294,) that a similar result ensued^fter the 
web had been stimulated by capsicum or an aromatic water. Even in 
the rapid flow of blood following these applications, minut globules 
could be seen creeping slowly along the transparent outlie of the 
larger vessels ; and as the arteries contracted, and the flow trough the 
other vessels became less rapid, the number of these globule-increased, 
their motion became slower, and many adhered to the side? of the ves- 
sels. If the stimulus used was rather strong or long /pplied, the 
number of sticking globules was so great as to prevent tie red cor- 
puscles from passing; and these becoming impacted ir increased 
numbers, gave to the obstructed vessels a uniform and deeper red 
colour. When the stimulation was moderate, and equally applied to 
the web, the stagnation usually took place first in some of those 
anastomosing veins in which the current is naturally slow and varying 
in direction ; but when a stronger stimulus (as an essential oil) was 
used, the stagnation speedily ensued at the point of its application ; in 
fact, unless very minute quantities were employed, the stagnation was 
almost immediate and extensive." 1 

1 Med. Gaz., July 23, 1841. It was not until after these observations were made that 
I became acquainted with similar ones, previously published by Mr. Addison, of Great 
Malvern, in the Med. Gaz. of Jan. 29th of the same year. The following description is 
given by Mr. Addison: — "In the frog's web, two days after the application of salt, in 
some of the larger capillaries or smaller veins, there are a great number of globules, No. 
3," (lymph globules;) "and it is quite extraordinary to observe the difference in move- 
ment between these round speckled globules and the oval ones; the blood globules pass 
in a continued stream, while in the same fluid, in the same vessel, are a great multitude 
of other (lymph, No. 3) globules, which do not move, or do so very sluggishly; every 
now and then they move slowly, apparently urged on by the repeated knocks they receive 
from the blood globules. It would appear that after the capillary vessels have been acted 
on by the salt, the round (lymph) globules accumulate in an unusual manner, and the 
blood globules repeatedly slide over and knock against them. In some of the vessels, 
there is a rapid stream of blood in the centre, whilst at the circumference there are many 



OBSTRUCTION IN THE CAPILLARIES. 



279 



416. I varied these observations in a great many ways, and always 
found considerable or continued irritation of the vessels in the frog's 
web to be attended with the appearance and adhesion of the colourless 
globules ; and that when the irritant used is at all strong, or frequently 
applied, many vessels become totally obstructed, get larger and redder 
in consequence of the accumulation of red corpuscles in them, (the 
blood liquor having passed on,) and exhibit to the naked eye all the 
appearance of inflammatory injection. One cause of obstruction seems 
to be comprised in two circumstances — the increased production of 
white globules, and their remarkable disposition to adhere to the walls 
of the vessels and to one another. It must however be stated that Dr. 
Hughes Bennett and Mr. Paget do not admit that the appearance of 
the pale corpuscles is so constant or essential as I have described it. 
In his observations on the circulation in the bat's wing, Mr. Paget 
traced the production of inflammation when very few pale corpuscles 
were present; and he considers their abundance in frogs to be an in- 
dication of unhealthiness in the animal. I much regret that my en- 
gagements do not permit me to return to these investigations ; which I 
cannot consider as definitely concluded by the negative observations 
since made. Of the abundant production of pale corpuscles in the 
frog's web under irritation, I have still no doubt; but that the same 
takes place in warm-blooded animals may be questioned, after the 
statements of Messrs. Paget and W. Jones. Still Mr. Gulliver assures 
me that he never failed to find pale corpuscles more or less abundant 
in the blood taken from inflamed parts of human subjects previously 
healthy, in whom a phlegmonous inflammation was the result of an ac- 
cidental injury. He also considers the inflamed vessefe to be the seat 
of an increased cell-formation. Such positive observations should have 
at least as much weight as opposite ones, which are negative ; and it 
may be remarked that the pale globules may escape notice in vessels 
in which the blood is stagnant, from their being completely covered by 
the red corpuscles which are found among them. 

The origin of the white corpuscles (§ 195,) seen in the blood, is in- 
volved in some doubt. They are distinctly spheroidal bodies, of a 
gelatinous consistence, and composed of granules, some of which have 
the distinct appearance of nuclei. According to Mr. Addison, 1 they 
are invested by a delicate membrane, and are granular cells, which, 
slowly by the action of water, more promptly by the operation of so- 
lution of potass, are caused to burst and discharge granules and mole- 
cules. In this respect, the colourless corpuscles differ from the blood 
discs, which burst speedily under the same treatment, and are almost 

stationary, round, spotted globules, which do not obey the impulse which urges the stream 
of blood, but remain, or move on slowly, by little starts, at uncertain intervals, and with 
unequal pace." This account corresponds very exactly with what I have myself observed ; 
but I should not consider the experiment so conclusive with regard to inflammation, inas- 
much as the chemical action of the salt might have been concerned in the production of 
the lymph globules. In my observations, I was careful to use no irritant which has any 
known chemical action on the blood. The greater prevalence of the pale globules in the 
motionless layer had been noticed by Wagner and others ; and their more abundant pro- 
duction in inflamed parts has been mentioned by Mr. Gulliver. 
1 Trans, of Provincial Med. and Surg. Assoc., 1843, p. 240. 



280 



INFLAMMATION. 



dissolved by either of these fluids. They appear to consist of fibrin, 
or rather deutoxide of protein; and, as in the case of other granular 
bodies formed in an albuminous fluid, each granule probably has a 
central nucleus or molecule of fat, which makes their specific gravity 
lower than that of the red corpuscles: hence their disposition to collect 
in the buffy coat of inflamed blood. The increased number of these 
bodies within the vessels of an inflamed part has been observed by Mr. 
Addison as well as by myself ; and from careful comparison instituted 
with uninflamed vessels, I infer that this increase is due, not merely 
to their being arrested in their transit through the inflamed vessels, 
but to their being actually formed in greater numbers, and that there 
is thus in the inflammatory process an increased cell-formation within 
the vessels, Nor is it difficult chemically to account for this produc- 
tion, if we consider the combination of causes which are operating in 
inflamed vessels. The blood liquid is highly charged with protein, 
which needs only a further process of oxidation to make it assume the 
solid form of deutoxide: this process is supplied by the free current of 
arterial blood (determination) which rushes into the obstructed por- 
tions, and brings the red corpuscles, the oxygen carriers, in such for- 
cible contact with blood liquor as favours the transfer of oxygen to the 
protein contained in it. As the protein becomes oxidized, it consoli- 
dates in a granular form, and the more readily around the oily mole- 
cules always diffused through the blood liquid; and these form the 
granules. But the granules also cohere in clusters, and form the pale 
corpuscles of various sizes which appear adhering to and creeping along 
the sides of irritated vessels. 1 This explanation corresponds with the 
sudden manner in which such numbers of pale corpuscles appear in 
the vessels of the frog's web, not only after its continued irritation, 
but also after its momentary rough handling or squeezing, whereby 
the vessels are partially obstructed, and so the force of the arterial 
current directed on their contents; the walls then appear studded with 
adherent and creeping corpuscles ; but as the impediment and the de- 
termination are not permanent, the lingering corpuscles are soon swept 
away and disappear: in inflamed vessels, on the other hand, their pre- 
sence is more constant; and their abundance in the blood in inflamma- 
tion has been long since noticed by Gendrin, Gulliver, Addison, and 
others; although more recently questioned by Mr. W. Jones and Mr. 
Paget. 

1 The accompanying diagram exhibits the appearance of a small portion of the capil- 
laries of a frog's web after the application of a particle of capsicum; and although per- 
haps not representing a type of healthy inflammation in a warm-blooded animal, yet pro- 
bably it affords some illustration of the process in its lower forms. The elliptical blood- 
discs (b) are running in the axis of the vessel, which is much narrowed by white globules 
adhering to the walls, or only slowly rolling along them. These globules are speckled 
with nuclei or granules, refract the light strongly, and when rolled on by the current, 
some of them become pear-shaped from their sticking to the vessel, thus forming a kind 
of dragging tail, seen very well in those marked (a;) on altering the focus, similar glo- 
bule? may be seen adhering to the other parts of the vessel. The shaded portion (c) is 
totally obstructed with white and red corpuscles, so impacted together as to form a ho- 
mogeneous red mass. I have often seen the particles at (d) exhibit a pulsating or oscil- 
latory motion, (corresponding with the action of the heart;) which, after a time, has 
seemed to succeed in breaking down the obstructing mass, which then has passed away 



ORIGIN OP PALE CORPUSCLES. 



281 



417. We have next to notice the peculiar disposition of the pale 
corpuscles to adhere to the "walls of the vessels. This disposition has 
been ascribed to a vital attraction ; but although it is made subservient 
to the purposes of life and organization, it appears to me to be the 
mere result of the physical property of adhesiveness common to soft 
solids of glutinous material. The same property is shown in the field 
of the microscope by the pale corpuscles sticking to the glass, whilst 
the red particles float in the liquid. It has however been objected 
that in blood drawn from the vessels "the white corpuscles do not show 
any tendency to adhere to each other or to the red particles, which 
they naturally would do if their surfaces were adhesive enough to cause 
them to stick to the walls of the vessels." 1 This objection has no force 
when it is considered that the white corpuscles do cohere most readily 
when brought into contact, and the reason why they appear separate 
in the field of the microscope, is because they at once stick to the glass 
and are not free to move and congregate like the red corpuscles. They 
do not usually adhere to the red corpuscles, because these are smooth, 
loose sacs of fluid, possessing exosmotic properties which are intended 
to keep them as loose and free from each other as possible, so that 
they may be carried with every motion of the current. 2 But there are 

in clots, leaving the vessel (c) studded with pale corpuscles like the rest; this result is 
observed whether the obstruction have taken place suddenly, or slowly, showing that in 
either case these corpuscles are present. 



b 




1 British and Foreign Medical Review, July, 1844, p. 107. 

2 These physical differences may be rudely illustrated by a clot of adhesive jelly and a 
thin bladder containing water; the jelly adheres to any plane or concave surface, so that 
it cannot be detached by inversion, the bladder rolls readily when the surface is inclined, 
and will not adhere even to the jelly. 



282 



INFLAMMATION. 



circumstances in which the red and pale corpuscles do cohere together; 
that is when their compression within the vessels prevents exosmosis: 
so also there is a condition of the walls of the blood-vessels in which 
the pale corpuscles adhere to them little or not at all; that is when 
osmosis through the walls of the corpuscles is as free as exosmosis, in 
the absence of all distention of the vessel ; and this explains why, in 
the instance before mentioned, the adherent pale corpuscles become 
detached as the circulation is restored to its natural state. 

The ordinary pale corpuscles of the blood certainly have a cell-wall, 
as described by Gulliver and Addison; but those recently formed in 
inflamed vessels do not appear to me to be so invested, and hence their 
more adhesive property. They soon, however, acquire this outer mem- 
brane, which seems to be nothing more than a pellicle of coagulated 
albumen or deutoxide of protein of a more solid consistence than the 
rest of the corpuscle. Globules of milk, oil, &c, in serum acquire an al- 
buminous coating, in like manner, as observed by Ascherson, Donne, 
and Gulliver. That much of the process of cell-formation is of a 
chemical character cannot admit of doubt; but in all probability 
the future behaviour of the cells thus formed will be determined by 
their capacity for vital properties, of which we know little. 

418. Except as the chief vehicles of oxygen, the red corpuscles 
seem to be less concerned than the white corpuscles, in the commence- 
ment of the obstruction of inflamed vessels: the red corpuscles are 
seen at first free, although twisting and struggling between the accu- 
. mulating white corpuscles : and so long as they do move along, they 
slioiv no disposition to cohere or form rouleaux: but if the obstruction 
be increased a little by another white corpuscle or two, so narrowing 
the path, that the red corpuscles can no longer find a passage, then 
these also stick, and forced by the current from behind, their flexible 
and elastic bodies become jammed in such numbers in the interstices 
of the white corpuscles, that the whole vessel speedily presents an 
almost homogeneous deep red colour, from the great accumulation of red 
particles, the liquor sanguinis having filtered through. This is the state 
of total obstruction, the process of which may be watched when the 
irritation is extremely gentle ; but in most instances this condition is 
produced so suddenly and extensively that the successive changes in- 
volved in it escape observation, and the contents of the vessels ap- 
pear to become at once stagnant and uniformly red, as if the blood had 
suddenly coagulated within them. The pale corpuscles are no longer 
distinctly visible ; and therefore their presence has been denied by some 
observers; but if in any part the current again forces a passage, some 
of those corpuscles may be seen adhering to the sides of the vessels. 1 

1 Mr. Wharton Jones and Mr. Paget whilst they both question that the pale corpuscles 
have much share in causing the obstruction of the vessels in inflammation, do not agree 
as to the condition of the red corpuscles. Mr. Jones states that he has seen these cluster 
together in rolls within the vessels of a bat's wing under irritation (Med. Chir. Trans., 
1853, p. 396;) whilst Mr. Paget asserts that "the corpuscles are indeed closely crowded, 
but they are not clustered, nor do they appear adherent" (Lectures on Surgical Pathology, 
1853, vol. i., p. 316.) Mr. Gulliver writes to me that he has observed the aggregation 
of both red and pale corpuscles within the vessels ; and he considers that the obstruction 
of the vessels is mainly due to this. He adds, "this pale cell-formation and dissolution 



EFFECT OF OBSTRUCTION. 



283 



We have formerly admitted as probable the influence of osmotic force 
in promoting and retarding the passage of the blood through the ca- 
pillaries (§ 295:) and as variations in this force were recognised as con- 
cerned in the obstruction of congestion, and in the increased flow of 
determination, it is reasonable to suppose that they obtain also in in- 
flammation, which comprises the conditions of congestion and determi- 
nation in different parts of the affected vessels. I suppose this osmo- 
tic force to depend on certain chemical affinities subsisting between the 
constituents of the blood and those of the vessels which convey it: 
and it is quite conceivable that a derangement in these affinities may 
impair, suspend, and even reverse the motion so far as it arises from 
this force. But this force is almost if not entirely limited to the ca- 
pillary vessels, and will be superseded in proportion as these get dis- 
tended, and the chemical relations between them and their contents 
become balanced. Very probably therefore this cause of obstruction 
in the circulation is rather connected with the incipient process of in- 
flammation than with its full development. 

419. The foregoing considerations warrant the conclusion that the 
process of inflammation is essentially more complex as well as further 
removed from the natural state, than either congestion or determina- 
tion of blood ; that it includes, in fact, both of these conditions toge- 
ther with certain changes in the blood within the vessels, and leads to 
farther results more extensive and more varied than those that follow 
from congestion and determination. There is increased motion or de- 
termination of blood to the affected part, with a more or less obstruct- 
ed flow through it: the force of the increased motion being partly 
expended on the arterial portions of the obstructed vessels (§ 414) and 
partly diverted into the collateral channels so abundantly supplied by 
the anastomosis of vessels (§ 410.) The obstruction in the vessels of an 
inflamed part seems to be due to several circumstances, which proba- 
bly vary considerably in different forms and degrees of inflammation. 
Thus in those which begin with congestion (§ 403) the obstruction may 
depend much on the increased mass of blood in the distended capillaries 
and the impaired elasticity of their coats (§ 300 ;) and in part on the 
diminution of the osmotic force (§ 295) which naturally favours the 
passage of blood through the capillaries. Changes in the blood proba- 
bly ensue sooner or later in all instances, and tend to increase the ob- 
struction ; but it is where the inflammation originates in direct irrita- 
tion (§ 402) that the blood in the vessels seems most speedily to become 
a cause of obstruction, even in opposition to an increased current di- 
rected on it through the enlarged arteries; and of these blood changes, 

is constant in true phlegmonous inflammation, and is indeed an essential part of it, as I 
infer from numberless observations on inflamed human parts." 

In his latest observations on the wing of the bat, Mr. W. Jones admits that " after the 
web had been much irritated, he has seen, in the venous radicles especially, colourless 
corpuscles accumulated in great numbers, as we so often see them in the frog" (loc. cit.) 

Although, therefore, I am ready to allow that the pale corpuscles may not be so uni- 
versally or largely concerned in causing the obstruction in the vessels of inflamed parts, 
as my observations formerly led me to suppose, yet I think that there is ample evidence 
to prove that they usually have an important share in the inflammatory process, and in 
contributing to its results. 



234 



INFLAMMATION. 



a diminution in the osmotic properties may be one; the formation of 
pale adhesive granules and compound cells is another; possibly the 
agglomeration of the red corpuscles may be a third ; and the result of 
this co-operation is that more or fewer of the capillaries are obstructed 
by a mass of red and -white corpuscles so amalgamated as to be no 
longer distinguishable. 

420. The effect of these changes, the essential conditions of inflam- 
mation, is, that much of the circulating force conveyed by the arteries is 
expended on their capillary terminations; the enlargement and tortu- 
osity of these capillaries, the production of corpuscles which adhere 
to their sides, and their consequent total obstruction by these and the 
red corpuscles together, seem to be so many several expedients used by 
nature to direct the force of the circulation to the particular vessels by 
which the process of reparation and nutrition is chiefly carried on. We 
have further suggested, that an obvious effect of this local direction or 
determination of force, is the more free supply of oxygen to the plas- 
ma, and that the resulting formation of a solid deutoxide of protein is 
the probable explanation of the production of the material of those 
white corpuscles which augment and complete the obstruction. This 
leads to the consideration of the farther changes effected by inflamma- 
tion. 

421. We have already found that an inflamed part is the seat both 
of determination, and of congestion or obstruction. It is this combi- 
nation that leads to the changes which characterize inflammation, and 
which, in extent and variety, exceed the changes from any other kind 
of hyperemia. The determination of blood to the obstructed vessels 
and to neighbouring parts is attended with the ordinary results of this 
process (§ 333, &c. ;) but to a greater extent than usual, because the 
cause of determination is more permanent. The congestion or stagna- 
tion has also its effects (§ 303, &c. ;) and these too are more marked 
and peculiar than usual, because the obstruction is more complete than 
in congestion in general, and because it is modified by the influence of 
a continued force of blood acting physically and chemically against it 
and by the new or increased cell-formation set up in and around the 
minute vessels. All these circumstances point out that the natural 
functions of the vessels must be much modified by inflammation, and this 
in different modes in different parts of the inflamed site. Thus, in the 
vessels which are the channels of an increased flow, the functions will 
be more or less exalted or excited ; whilst in those that are obstructed, 
vital properties will be more or less depraved and impaired. It is the 
approximation of two such opposite conditions, excitement and inter- 
ruption of living actions almost in the same spot, that renders continual 
inflammation so seriously destructive to structure as well as to function. 

422. Inflammation at first much exalts sensibility (§ 133) and con- 
tractility (§ 111 ;) causing tenderness, pain, and spasm. But the ob- 
structed circulation may cause a suspension of these properties (§ 273) 
in the centre of the mischief, whilst in surrounding parts, the seat of 
determination, they are exalted. The sympathetic relations (§ 152, 
156) of the inflamed part are also commonly affected. Natural secre- 
tions are either suspended by inflammation, or altered by the addition 



EXUDATION CORPUSCLES. 



235 



to them of various modifications of the serous and albuminous parts of 
the blood. This involves the change of the nutritive process, which is 
so important and early a part of inflammation, that it must be noticed 
more fully. We shall recur to the other effects of inflammation under 
the head of symptoms. 

423. The effusions from inflamed vessels are, at an early period, 
much the same as those produced by tense congestion (§ 805 — 8) and 
determination of blood (§ 340, 1 ;) but they commonly occur in greater 
abundance, contain more animal, fatty, and saline matter ; and, as the 
inflammation advances, sometimes present appearances not found in 
cases of mere congestion or determination. Thus the effusion at first 
is a thin serum, causing swelling in complex textures, accumulating in 
the dependent parts of serous cavities, or diluting the secretion of the 
more simple mucous membranes. But soon fibrin is also effused, a part 
of which may concrete into coagulable lymph, or still remain dissolved, 
as in the liquor sanguinis. Fatty matter is also present, both in the liquor 
sanguinis and in coagulated fibrin; it is visible under the microscope in 
the form of molecules, separate and aggregated. 1 Thus an inflamed 
pleura becomes coated with a film of lymph; and the clear body effused 
into the sac, when removed from the body, sometimes spontaneously 
separates into a fibrinous clot and serum. When this occurs in com- 
plex textures a hardness is given to the swelling, as in phlegmon of 
cellular membrane, hepatization of the lung, &c. In mucous mem- 
branes, there may be thickening of the submucous texture, and the 
mucous secretion often becomes unusually viscid. The salt taste of 
the expectoration in the early stage of bronchitis denotes the increase 
of saline matter in it. The presence of the chlorides in the substance 
of an inflamed lung has been shown by Dr. L. Beale to correspond 
with their absence from the urine in pneumonia. Thus the inflamed 
vessels seem to acquire for the time a new excretory action. 

424. The microscope has supplied much detailed and precise in- 
formation regarding the nature of inflammatory effusions, although 
further research is yet needed, into their varieties and relations to 
each other. In the frog's web, after inflammation has continued some 
hours, there appear outside of the vessels, (especially where the strongest 
current encounters the most complete obstruction,) white globules or 
corpuscles, with specks in them, exactly like the pale granular globules 
within the vessels (§ 415.) These are found in most kinds of inflam- 
matory effusions, and are called exudation corpuscles, granule cells, 
or fibrinous globules. Mandl supposes them to be merely consolidated 
globules of fibrin, and states, that the liquor sanguinis may be seen to 
coagulate in similar globules on the glass of the microscope. But these 
latter have been shown by Gerber to be mere albuminous granules, 
without regularity of form, and quite unlike the true exudation cor- 
puscles, which also consist of granules, but have a defined outline, and 
in many instances an investing membrane, whence the term granule 
cell (Vogel.) In addition to these bodies, the fibrin effused by inflamed 
membranes also contains a mesh of extremely fine fibres, first noticed 

1 These were first described by Mr. Gulliver (Med. Chir. Trans., vol. xxvi.) 



286 



INFLAMMATION. 



by Messrs. Magendie, 1 Gulliver, 2 and Addison. 3 These observers also 
describe the nucleated or granulated corpuscles as occurring among 
these fibres, together with many more minute molecules and granules, 
which appear to be similar to those in the corpuscles. Some portions 
of solid effused matter, however, present no distinct structure, but are 
either irregularly granular like coagulated albumen, or completely 
amorphous and homogeneous (Vogel,) hyaline of Gerber. Now, some 
or all of these conditions are presented in inflammatory effusions, but 
they occur in very various proportions, and in different modifications, 
as will be specified hereafter. In the following summary of the ele- 
mentary solids of inflammatory effusions I am indebted to my friend, 
Mr. Gulliver, for several suggestions and corrections. 

1. Molecules, of extreme minuteness, from g-y-J o o to s thj o °f an mc ^ 
in diameter; smooth and apparently spherical; composed of fatty 
matter, oleine (Davy and Gulliver,) smaller primitive molecules; Gruby, 
minute free cell-seeds ; Gulliver.) 

2. Granules (Gerber, Addison, Henle; larger primitive molecules, 
Gruby,) measuring from T 2o-oo" to Woo °f an i ncn ? appearing as a 
light spot surrounded by a dark circle ; probably consisting of a film of 
albumen or deutoxide of protein investing a central molecule of fat. 

3. Fibrils, extremely fine; interlaced and decussating; the same as 
those seen in the buffy coat of the blood and other concrete fibrin. 
Larger fibres, swelled and nucleated at the centre, and tapering off at 
the extremities, are also sometimes met with. 

4. ^Exudation corpuscles, compound granules, granule cells, aggre- 
gation corpuscles, cytoid bodies, "of an average diameter of T ^ ^ of 
an inch; pale or dark in transmitted light, according to their density, 
or more or less of the aggregation of their component parts, which are 
chiefly molecules (1,) either merely coherent in rounded or oval masses, 
or connected by minute granular matter, sometimes with a delicate in- 
vesting cell-membrane" (Gulliver.) Being chiefly made up of mole- 
cules and granules, they consist of fat and concrete albumen or protein. 

5. Pus Globules, "of an average diameter of of an inch, and 
therefore smaller than the exudation corpuscles " (Gulliver.) They are 
also more essentially and distinctly cells, containing liquid, with more 
or fewer granules, some of which are larger than the rest, and are 
called nuclei. The cell-membrane consists of protein, which with fat 
also forms the granules. 

6. Irregular granular, flaky, and hyaline matter; the former, con- 
sisting of protein and fat; the latter albuminous also, with filamentous 
matter resembling fibrin, but chemically different. These constitute 
the chief materials of tuberculous and other cacoplastic and aplastic 
deposits. They often exhibit traces of cells and fibres, and sometimes 
numerous small cells, but of an imperfectly formed or degenerated 
kind. 

In addition to the above, inflammatory effusions generally contain 

1 Lancet, 1838. 

2 Note to Gerber's General Anatomy, p. 31, and Introduction to Hewson's Works, p. 45. 

3 Med. Gaz., April 15, 1841. 



INFLAMMATION — RESULTS. 



287 



the solids natural to the part, such as mucous globules, epithelium 
scales, epidermis, and also blood corpuscles. 

425. Of these elementary solids of effusion, the fibrils certainly form 
from liquor sanguinis when out of the vessels, and even after its re- 
moval from the body (Addison and Gulliver;) but it is a question 
whether the other varieties concrete spontaneously from the liquid 
fibrin, or grow from germs, (molecules or granules,) that are disseminated 
from the vessels or adjoining textures. The close resemblance of the 
exudation corpuscles and their contents to the white globules and gra- 
nules so abundantly produced in the blood of the inflamed vessels, would 
seem to indicate that these bodies are identical; but it is not easy to 
understand how such can pass through the walls of vessels, in which no 
pores are visible under the highest magnifying powers. Mr. Addison 
has, indeed, represented the white globules as first passing into the 
substance of the wall of the blood-vessel, and then being thrown out 
from it; but this would seem too slow a process. It would appear more 
probable either that nuclei or molecules, too small to be discernible, do 
pass out through the wall, and then grow into compound granules 
(granular exudation and pus corpuscles ;) or that the corpuscles them- 
selves are formed by coagulation in the effused liquor sanguinis as 
the fibres of fibrin certainly are. 

426. These solid products of inflammation are the materials out of 
which new membranes, textures and deposits are formed ; and present 
every variety of much, little, or no plasticity or capacity of organiza- 
tion, from that of perfect cicatrices and false membranes, down to that 
of yellow tuberculous matter. 1 As we shall have to notice these fur- 
ther when speaking of results of inflammation, we shall now pass on to 
consider the further consequences and symptoms of inflammation. 

427. Inflammation is always attended with more or less effusion. 
When the inflammation is slight, this effusion may remove it by unload- 
ing the engorged blood-vessels : but where the inflammation is more in- 
tense, that is, where the obstruction is considerable and the determina- 
tion of blood strong, the effusion may go on to a great extent without 
resolving the inflammation. It is then that the more serious effects 
of inflammation result. The effused matters press on and pervade the 
adjoining textures, derange their nutrition, and impair their cohesion ; 
and thus takes place that softening of textures, which occurs chiefly 
in such complex structures as retain the effused matter. The conti- 
nued obstruction in the inflamed part leaves the veins and lymphatics 
free to absorb, and the high pressure and determination of blood tend 
rather to promote this process of absorption. Hence, as new matters 
are effused, the old texture is compressed, disintegrated, and absorbed ; 
the finer exudation corpuscles and fibres are removed or altered, and 

1 This statement which is in accordance with the observations of the most esteemed 
pathologists of the present day, very nearly corresponds with the views which I published 
more than a quarter of a century ago, at a time at which, and long after which, pus and 
tubercle were considered to be matters sui generis, of nature and origin totally different 
from coagulable lymph. They always appeared to me to be only modifications of the 
plastic material of the blood, presented in different conditions, and this seems now to be 
the commonly received opinion. 



288 



INFLAMMATION. — SYMPTOMS — EFFECTS. 



the large pus globules alone remain and accumulate: this is suppu- 
ration. Or if the original obstruction of the inflamed vessels be ex- 
tensive, or have been rendered so by the subsequent effusion, the sup- 
ply of blood may be so stopped in a part, that it dies, and the dead part 
may then either be only dissolved and absorbed where it is connected 
with the living textures, and thus be separated in form of a slough; 
or if the obstruction be yet more extensive, the dead part may pass 
into decomposition before it can be separated; thus occur gangrene 
and sphacelus. If the inflammation be of a lower kind, the obstruc- 
tion less complete, and the effusion more gradual, the nutrition of the 
natural texture is only impaired, not arrested, and from the increased 
deposition of solid matter induration or consolidation takes place. 

SYMPTOMS AND EFFECTS OF INFLAMMATION. 

428. We have now described the process of inflammation in its inti- 
mate nature and phenomena ; we have next to notice its more obvious 
effects on function and structure, which indeed are the symptoms of its 
existence. These symptoms may be divided into local and general; the 
local occurring chiefly in the part which is the seat of inflammation ; 
the general affecting the system at large. 

LOCAL SYMPTOMS. 

429. We have before stated that the local symptoms are commonly 
more marked, and earlier in order of occurrence if the inflammation be 
excited by local irritation (§ 402 ;) the fever which afterwards super- 
venes may disguise the local symptoms. The chief local symptoms 
have been already mentioned in the definition, redness, heat, pain, and 
sivelling, but to these must be added various disturbances of the func- 
tion of the part affected. We go on to explain and illustrate these 
symptoms. 

430. The redness of an inflamed part is obviously due to the increased 
quantity of blood in its vessels. These vessels are all much enlarged, 
so that they receive many more red corpuscles than usual; the finest 
capillaries, which commonly are invisible from admitting only the li- 
quor sanguinis, and a row of one or two red corpuscles, are now dis- 
tinctly coloured from the number of these bodies that pass into them. 
The enlargement is not uniform; some vessels are elongated and tortu- 
ous, as well as distended ; others are varicose or saccular, as was first 
described by Mr. Kiernan, and more recently by Kolliker and Mr. 
Paget. Some observers have thought that new vessels are formed by 
the blood forcing its way through the textures. I have never seen this 
in the frog's web, and Mr. Paget denies its occurrence in any case ex- 
cept in inflammatory lymph; but it has been said to take place in some 
textures which are not naturally vascular, such as the interior part of 
the cornea, and cellular cartilage (Toynbee.) But the microscope shows 
that the redness of inflammation arises from the stagnation of blood 
in the vessels, as well as from the entrance of numerous red corpuscles 
into capillaries that do not ordinarily contain them. The colour of in- 
flamed parts is much more red than is that of parts simply congested, 
or through which a current still passes : this has been referred to the 



LOCAL SYMPTOMS. 



289 



accumulation of the red corpuscles which then takes place (§415, 417, 
note:) this crowding of the reel corpuscles has also been recently noticed 
by Mr. Paget (Lectures, vol. i. p. 296.) The obstructed vessels ap- 
pear so impacted with colouring matter to their outmost limits, that the 
shape of the blood discs and of the white corpuscles is no longer dis- 
cernible: yet these are still often present; for when an obstructed 
vessel re-opens, the red mass breaks up into clots and particles, and in 
many instances white corpuscles are left sticking to its walls. (See 
note, § 416.) It is obvious, therefore, that the obstructed vessels be- 
come stuffed, as it were, with red as well as white corpuscles, which 
cause a brighter and stronger red than that produced in mere conges- 
tion. In many instances, too, it may be seen that the redness of an 
inflamed part is augmented in spots and patches where blood is extra- 
vasated; this happens especially in some varieties of inflammation. 

The redness of inflammation presents great modifications according 
to the number and distribution of the vessels of the part; but its most 
essential seat being in the capillaries, its most constant character is a 
diffused or capilliform redness. This is commonly far more vivid and 
general in the living than in the dead body. In the skin and mucous 
membranes during life it is often seen as a uniform blush of colour, 
varying from a delicate pink to a bright crimson. After death this 
blush has sometimes entirely disappeared ; but commonly more or less of 
it remains; and on examination with a lens, it is found to consist chiefly 
of numerous vascular strise, meshes, or points, with here and there 
larger vessels and ramifications also injected. But the large venous 
vessels are distended much less generally than in congestion (§ 280,) 
and the redness is therefore less arborescent and ramiform. To ex- 
plain the reason of the disappearance of inflammatory redness after 
death, we must bear in mind that much of the colour depends on de- 
termination of blood (§ 326) which is maintained by the action of the 
heart, distributed through the arteries; and that when this force 
ceases in death, the tonic contraction of the arteries, which survives for a 
few hours, perhaps aided by osmotic force (§ 295,) expels the blood 
from the vessels (§ 120.) A similar effect is sometimes produced 
during life, by cardiac syncope. The redness that remains after death 
seems chiefly to depend on the vessels which have become totally ob- 
structed and impacted with blood, or which have been long congested 
and have lost their tone (§ 295.) This furnishes a useful means of dis- 
tinguishing the comparative prevalence of the several elements of in- 
flammation in different cases. Thus when the redness disappears after 
death, we know that the predominant condition was local determina- 
tion of blood (§ 409) without much obstruction or permanent conges- 
tion. This is observed in erythematic and diffused membranous inflam- 
mations, the cutaneous inflammations of eruptive fevers, and the early 
stages of all inflammatory action excited by moderate local irritation 
(§ 402, 415.) On the other hand, if much redness remains after death, 
it may be inferred that obstruction or congestion of the vessels has 
existed to a great extent. This happens especially in phlegmonous 
inflammations, those of parenchymatous tissue, those which have' ad 
19 



290 



INFLAMMATION — SYMPTOMS, 



vanced to a certain high degree of intensity, and those which have 
originated in congestion (§ 403.) 

The florid hue of the redness is also during life a sign of the pre- 
dominance of determination, for it shows that the blood is chiefly ar- 
terial and not stagnant. Where congestion prevails, or where the 
blood has been long stagnant in many vessels, the colour is deeper ; 
but it is rarely so deep as in pure congestion, for the presence of white 
globules tends to lighten it or give it a florid tinge, and it is probable 
that the red corpuscles stagnant in the vessels, still receive oxygen 
from the communicating arteries, which are the seats of determination 
of blood. In the dead body these distinctions are not equally avail- 
able, for the arterial part of the blood may have been removed by the 
contraction of the vessels, or darkened by stagnation ; and the livid 
portions speedily become florid on exposure to the air. 1 

The progress of inflammation modifies the redness. The colour be- 
comes more florid and deeper as the inflammation advances to its acme ; 
it then becomes either livid before it subsides, or paler from the pre- 
sence of effused matters. In complex textures, effused lymph or pus 
often changes the redness to pink, flesh colour, drab, or yellow. 

431. The heat of inflammation is obviously dependent on the in- 
creased flow of blood to, and through, the part; and it may be consi- 
dered to represent the amount of determination of blood concerned in 
the inflammation. Hence it is great in extensive and active inflamma- 
tion, and is generally proportioned to the florid redness or arterial vas- 
cularity. It is not certain whether the high temperature of an in- 
flamed part is caused by the augmented changes going on in that part, 
or whether it arises merely from the greater quantity of warm blood 
which passes through it. John Hunter made some observations to de- 
termine this point, and never found that the temperature of an in- 
flamed part was raised above that of the interior of the body, which it 
might be expected to be if inflammation was in itself a calorific pro- 
cess. That extensive inflammation raises the heat of the whole body, 
as well as of its own site, is quite certain ; but this may be simply by 
causing general excitement, especially of the circulation and respira- 
tion, and by repressing the perspiration and other exhalations, by which 
the body is naturally cooled. It seems, however, quite consistent with 
analogy to admit that inflammation, as a process of increased vascular 
action, may generate heat; and inasmuch as there is an augmentation 
of the red corpuscles in the part, which are supposed to be chief agents 
in the generation of heat (through the oxygen which they supply,) we 
see a reason why the calorific process may be exalted in the inflamed 
part. Increased heat is a very important and valuable symptom cf 
inflammation, since it is more constantly discernible than any other, 
and serves to distinguish inflammation from congestion and nervous 
irritation, which may resemble it in other points. But to indicate in- 

1 I have often in the dead-house seen mere congestive redness mistaken for inflamma- 
tory, because it was florid, from the action of the air, or from the translucence of a sub- 
jacent "white structure. Frequently, too, the claret stain of arteries and intestines is 
mistaken for inflammatory redness; a common lens will prove it to be not so, by showing 
that it is not vascular. 



LOCAL SYMPTOMS — SWELLING. 291 

flammation the heat must be continued, and not merely come in flushes 
of simple determination of blood. Generally the skin is dry as well 
as hot: but it may be perspiring, and yet a temperature, higher than 
natural, may be sustained. 

432. The swelling of an inflamed part is caused in some degree by 
the enlargement of the vessels, but chiefly by the effusions from them, 
and it will be therefore proportioned to the amount of these ; but the 
situation, form and degree of the swelling will also greatly depend on 
the natural structure of the part inflamed. In serous membranes, the 
vessels being comparatively few, admit of but little enlargement; and 
the effusions, not being retained by complexity of structure, soon over- 
flow externally and accumulate in the most dependent parts of the se- 
rous sacs, causing dulness on percussion, and sometimes fluctuation in 
the chest and abdomen, and when in large quantity distending their 
cavities. Mucous membranes are more vascular and complex in struc- 
ture: hence the early enlargement of vessels causes some thickening; 
but the swelling is chiefly due to interstitial effusion in the submucous 
tissue (so manifest in coryza and cynanche :) this effusion, when merely 
serous, soon passes off in the thin flux which attends catarrhal inflam- 
mations, and the swelling may subside with it: when the effusion is 
more solid ? the swelling remains longer, is attended with a more viscid 
secretion, and subsides only when this secretion becomes opaque, and 
somewhat fat in its composition. The skin presents great variety in 
the swelling as well as in the redness caused by inflammation. Some- 
times the swelling is diffused and hard, as in cutaneous erysipelas. In 
urticaria the same kind of hard swelling occurs in spots or patches, 
and in places the effusion supersedes the vascular redness, causing white 
centres or wheals. In tubercular inflammations of the skin the red- 
ness and swelling are still more circumscribed, and the effusion seems 
to be chiefly solid. In papulae the swelling is even more restricted, 
and confined to a point. In blebs and vesicles, the effusion is between 
the cuticle and the true skin, and the swelling is confined to corre- 
sponding patches or small spots. Inflammation of cellular texture is 
attended with considerable swelling ; which is diffused, ©edematous, and 
pitting on pressure when the effusion is serous; more tense when there 
is fibrin with the serum : and hard and circumscribed (as in phlegmon) 
when the matter effused is chiefly fibrin. Parenchymatous organs, in 
like manner, are remarkably swelled by inflammation. The liver, kid- 
neys, testicles, lymphatic and other glands, attain a large size from the 
mere distention of their blood-vessels; and we have noticed a similar 
result from mere congestion (§ 293;) but still more inflammation does 
not continue long in these structures without causing effusion, which 
may constitute swelling, varying in its firmness according to the pro- 
portions of serum and lymph thrown out, and to the resistance of their 
investing membranes. The lungs, from their porous structure, do not 
swell much in bulk ; but the effusion displaces the air in their cells, 
thus increasing their weight, and if the effusion abound in lymph, con- 
verts them into a more or less solid liver-like mass (hepatization.) 

433. ^The pain of inflammation results from that exaltation of sen- 
sibility (§ 135) which determination of blood produces (§ 333,) and from 



292 



INFLAMMATION — SYMPTOMS. 



the tension or pressure arising from the swelling. The amount of pain 
will therefore depend much on the natural sensibility of the part, the 
degree in which determination of blood predominates, and the tension 
or pressure induced. The severest pain arises where all these circum- 
stances co-operate, as in inflammation of the pulp of a tooth, the sheath 
of a nerve, or the lining of a bony canal, like the auditory meatus, &c. 
In other cases pain is chiefly felt when the inflamed part is pressed or 
stretched, constituting excessive tenderness. Thus the pain of peri- 
tonitis is felt when the abdomen is compressed, or when its walls are 
strained by coughing or vomiting; the stitch of pleurisy is perceived on 
taking a full breath: the pain of external inflammation and rheumatism, 
on motion or pressure on the limbs. In enteritis there is often little 
pain until the intestines become spasmodically contracted in some parts, 
and distended in others, by flatus and other contents : the pain may 
vary, whilst the inflammation remains the same. Parenchymatous or- 
gans and mucous membranes being comparatively soft and yielding in 
texture, are not the seat of much pain when inflamed. In the early stage, 
pain, with heat, may indicate the activity of inflammation, that is, the 
prevalence of determination of blood. In the more advanced stages, 
the pain rather bears relation to the amount of tension from swelling 
or effusion, and is commonly relieved when these become more diffused, 
or end in suppuration. 

434. Besides pain and tenderness, sensibility increased by inflam- 
mation sometimes exhibits other modifications, such as feelings of sore- 
ness, tingling, heat, itching, &c. Peculiar sensations are also excited 
in the organs of special sense when they are inflamed, such as noises 
in the ears, painful and disturbed vision, &c. The peculiar sensibility 
which excites the motions of sneezing, coughing, vomiting, micturition, 
and defecation, is exalted, when the Schneiderian membrane, the 
lining of the upper part of the air-tube, the cardiac end of the stomach, 
the bladder, and the rectum, are respectively inflamed. Other sympa- 
thetic sensations (§ 156) excited by inflammation are peculiar to dis- 
ease, as the pain in the shoulder-blade, with inflammation of the liver ; 
pain in the testicle, with inflammation of the kidney ; pain of the glans 
penis, in inflammation of the bladder; pain of the knee, with inflamma- 
tion of the hip. 

435. Contractile fibre is not itself prone to inflammation ; when the 
parts contiguous to it are inflamed, the effect is commonly first to in- 
crease its irritability (§ 113,) and subsequently to impair it, probably 
by exhaustion. Thus the heart, when its membranes are inflamed, acts 
first with great force and frequency, but subsequently with feebleness 
and irregularity. When the intestines, bladder, or air-tubes are in- 
flamed, there is contraction followed afterwards by more or less weak- 
ness of the muscular fibres of these parts. 

436. Other functions are somewhat similarly affected under the in- 
fluence of inflammation. In inflammation of the brain and its mem- 
branes, there is commonly at first more or less excitement of the sen- 
sorial powers, leading to delirium, hallucinations, and convulsions; 
afterwards stupor, coma, and paralysis ensue. In the early stage of 
inflammation of the spinal cord, there may be tetanic convulsions; 



CONSTITUTIONAL SYMPTOMS. 



293 



afterwards follows paralysis. Often symptoms of partial excitement 
are conjoined with others of interruption of function; and this is not 
extraordinary, seeing that inflammation comprises diminished as well as 
increased flow of blood, and that the former generally predominates as 
the inflammation advances and effusion proceeds. Inflammation of the 
lungs causes dyspnoea: that of the stomach interferes with digestion: 
inflammation of the kidneys suspends or impairs their secreting power, 
&c. Further details belong to special pathology. 

CONSTITUTIONAL SYMPTOMS OF INFLAMMATION. 

437. The irritation of inflammation frequently extends itself to the 
system at large. The functions of the whole body are more or less 
disordered. The contractions of the heart are more frequent and 
forcible than usual : the arterial tonicity is increased (§ 121 ;) hence 
the pulse is quick and hard: the skin is dry and hot: the appetite and 
strength are impaired: and the natural secretions are diminished and 
otherwise disordered. This is inflammatory fever. 

438. Among the most important general effects of inflammation must 
be noticed the change in the condition of the whole blood. We have 
before noticed, that there is an excess of fibrin and of the colourless 
globules in the blood in inflammatory diseases (§ 195 ;) and that the 
separation and contraction of this fibrin (§ 203, 4) take place in an 
unusual degree, and produce the peculiar buffed and cupped appear- 
ance of the clot so remarkable in inflamed blood (§ 208.) This excess 
and separation of fibrin displayed in the buffy coat is commonly pro- 
portioned to the extent of the inflammation and its duration in an ac- 
tive state. This suggests the view that the change in the blood is 
altogether produced in the blood-vessels in and near the inflamed part: 
and that increased development of white globules, sometimes seen by 
aid of the microscope (§ 415,) is a kind of demonstration of this pro- 
duction. This supposition derives support from the fact, that blood 
drawn directly from an inflamed part is more buffed than that drawn 
from a distant part. 1 The excess and separation of fibrin is more re- 
markable in inflammations of serous membranes than in those of mu- 
cous membranes, or parenchymata, which may perhaps be ascribed to 
the former inflammations being attended with less local vascular dis- 
tention and effusion of the exudation corpuscles and fibrin. Acute 
rheumatism presents in the highest degree, the buffing and cupping of 
the blood ; perhaps because the inflammatory irritation arising from 
the presence of offending matters in the blood itself 2 (§ 251) affects a 
great many vessels, yet without completely obstructing them, so that 
then determination of blood predominates over congestion: although 
there may be much inflammation and effusion of the early kind (§ 423,) 
this does not lead to suppuration, or other of the more destructive 
changes which follow inflammation. It has been before mentioned 
(§ 245,) that an increased activity of circulation and respiration might 

1 I have observed this even in blood drawn by cupping on a part inflamed by the pre- 
vious application of a blister. 

2 The buffed appearance of the blood in inflammatory dropsy admits of a similar in- 
terpretation (g 385.) 



294 



INFLAMMATION — SYMPTOMS. 



contribute to augment the fibrin of the blood in acute rheumatism and in 
other inflammations not impairing the respiratory function ; but it was 
then objected, that the increase of the fibrin is sometimes observed in 
rheumatism where there was not much acceleration of the pulse and 
breathing; and, on the other hand, in fevers in which the pulse and 
breathing are much hurried, the fibrin of the blood is even diminished 
(§ 196.) It was found, by Andral and Gavarret, that in fevers, the 
occurrence of local inflammation always caused an increase of the fibrin 
in the blood. 

It seems pretty clear, then, that the increase of fibrin, and the ex- 
altation of its contractile and separating qualities originate in the 
vessels of the inflamed part, and must be regarded as an augmentation 
of one of the processes of nutrition effected by inflammation. A simi- 
lar augmentation takes place in the vessels of the uterus during the 
latter months of pregnancy, when the blood drawn generally exhibits 
a buffed appearance ; and although the same appearance is not com- 
monly presented by blood drawn from fast-growing children during 
health, yet in them it is very readily induced by inflammation, and 
the plastic products are then unusually copious. In young pulpy 
growing parts the pale corpuscles are very abundant, and Mr. Gulliver 
long since applied to them the term " embryo flesh and blood." (Tr. 
of Wagner's Physiology, p. 251.) It has been mentioned (§ 415,) that 
in young frogs even in health, many white globules are seen in the 
blood-vessels adhering to or moving slowly along their sides ; and this 
appears to be a proof that it is the same nutritive or plastic process, 
which is exalted to its highest degree in acute inflammation. 

439. It has been supposed that the hyperfibrinous state of the blood 
is the cause of the general excitement constituting the symptomatic 
fever accompanying inflammation ; but it must be remarked that this 
fever frequently rises high before the blood has begun to exhibit the 
buffy coat, that it often subsides when the buffy coat is most abundant, 
and that it is sometimes wholly absent when the blood is both buffed 
and cupped, as in subacute rheumatism. It is very probable, however, 
that the excess of fibrin may contribute to the excitement ; it certainly 
materially affects the duration and products of the inflammation. 

440. In inquiring into the/pathology of inflammatory fever, we must 
bear in mind, that it sometimes precedes the distinct development of 
the local inflammation, being in fact a general excitement cu* reaction, 
immediately induced by the influence of the exciting cause. This is 
especially the case where inflammations are produced by cold, fatigue, 
and other causes, which first induce congestion (§ 403.) The operation 
of these influences, is at first depressing to the whole system; this is 
marked in the cold stage of the fever, where there is weak pulse, cold- 
ness of the extremities and surface, general pallor, chilly and various 
uneasy feelings, dejection of spirits, and depression of strength. After- 
wards ensues the reaction, beginning with rigors, accelerated pulse 
and breathing, sometimes vomiting, and other signs of functional dis- 
turbance: the skin then becomes hot, the pulse hard, as well as fre- 
quent; uneasy feelings in the head, back, and limbs are experienced, 
as well as thirst, loss of appetite, restlessness, and much weakness. 



CONSTITUTIONAL SYMPTOMS — FEVER. 



295 



Now it is during, or after the establishment of, this reaction that the 
local symptoms of inflammation become prominent. During the cold 
stage there may have been congestion of the affected organ (§ 303,) 
impaired function, and more or less uneasiness; but now pain (§ 433,) 
heat (§ 431,) and various symptoms of local irritation (§ 434,) appear; 
and frequently, as these become developed, the general disturbance is 
somewhat reduced or modified. In eruptive fevers, the general dis- 
turbance and functional disorder is nearly always greatest before the 
eruption (or local inflammation) occurs. In inflammations resulting 
from cold or fatigue, the first disorder is often very like continued 
fever, but this becomes simple inflammatory fever as soon as the in- 
flammation is pronounced. In other cases, again (chiefly such as origi- 
nate in local irritation,) (§ 402,) the inflammation is developed, and its 
symptoms are prominent, before the symptomatic fever is excited. 
Generally, however, the fever is in proportion to the severity or active 
character of the inflammation ; if it were always so, we might conclude 
that it was simply the result of a reaction from the disturbance of the 
circulation produced by the inflammation ; but we sometimes find in- 
flammation of trifling organs, such as the tonsils, attended with a very 
smart fever; and much greater disturbances of the circulation, such as 
congestions of the lungs and liver, without any fever at all. It seems 
more probable, then, that the fever accompanying inflammation arising 
from local irritation, is caused by an influence that is propagated 
from the inflamed part to the heart and arteries through the medium 
of the nerves. The same influence also probably sustains the inflam- 
matory fever, in the cases before noticed in this paragraph, where the 
first febrile movement seems to be clearly the result of reaction. In 
fact it seems now«to be a growing opinion that febrile heat is more or 
less directly dependent on derangement of functions of the nervous 
system, especially the sympathetic nerves which have immediate influ- 
ence on the heart, blood-vessels, and respiratory apparatus. The ex- 
periments of Bernard and others seem to show that injury to these 
nerves causes an increased action of the heart, enlargement of the ves- 
sels, and an augmentation of heat — in short the phenomena of fever: 
and it is assumed by Virchow as an inevitable inference that fever is 
the result of increased change in the tissues under the immediate influ- 
ence of a modified condition of the nervous system. 

441. It. still remains unexplained why, in fever, the circulation and 
some other of the vital functions are excited, whilst others, such as se- 
cretion, muscular energy, and the appetites, are much impaired. We 
may partly solve this difficulty, by bearing in mind the fact that the 
excitement is not one of a healthy kind ; it is attended with an exces- 
sive tonicity of the arteries (§ 121,) which is the cause of the hardness 
of the pulse, and which may transmit the blood through the capillaries 
too rapidly to permit of its undergoing the proper changes by excre- 
tion. It is also possible that the secreting powers (§ 158) may be 
even more directly impaired by the inflammation, or its cause; for it 
is certain that, either as cause or effect, imperfect secretion is one of 
the most prominent features of fever in general. The bowels are gene- 
rally costive; the urine scanty and high-coloured; the skin dry; and 



296 



INFLAMMATION — SYMPTOMS. 



the tongue clammy ; ulcers or sores also, that have been discharging 
before, often become dried up. And so, again, on the subsidence of 
the fever, all these secretions are restored. 

Finally, we may sum up the causes of the symptomatic fever of in- 
flammation as being comprised under three heads: — 1. Reaction after 
the depression induced by some such influences as cold, fatigue, &e. 
2. Irritation communicated to the heart from the seat of inflammation, 
probably through the nerves; this acts most powerfully in irritable 
constitutions. 3. The altered condition of the blood, consisting in an 
excess of fibrin, and a retention of excrementitious matter; this espe- 
cially sustains the fever. 

442. The fever accompanying inflammation is generally high — that 
is attended with hard pulse, hot skin, and general excitement — in the 
young, the sanguine (§ 38,) and plethoric (§ 279 ;) those, in short, in 
whom the vascular system is naturally active (§ 401.) On the other 
hand, it is commonly low — that is, with weaker, though sharp and 
quick pulse, less general heat of skin, and with tongue more foul, and 
functions rather oppressed or disordered than excited — in persons of 
phlegmatic temperament (§ 40,) and in those who are weak from age, 
disease, malnutrition, intemperance, or undue confinement. The type 
or character of the fever also varies with the seat of the inflammation, 
and the particular textures affected, although the variation is less con- 
stant than it is generally represented to be. It is commonly stated, 
that the fever is high in inflammations of serous and fibrous textures, 
and in phlegmonous inflammation of cellular texture; that it is low in 
inflammation of the stomach and intestines, kidneys, large joints, and 
in diffuse inflammation of cellular texture; and that it is of an inter- 
mediate character in inflammation of mucous membranes and parenchy- 
matous structures. Clinical experience however shows that there are 
many exceptions to these statements ; and where the type of the fever 
is affected by the texture, it is chiefly shown in the intensity of the 
inflammation, and the nature of its result. Diffused inflammations, of 
slight intensity, often excite very little fever, and cause few local 
symptoms. The reverse is the case with very acute inflammations 
even of moderate extent. 

443. The nature of the exciting cause, or some co-operating in- 
fluence, often materially affects the type of the fever. The inflam- 
mation occurring after serious accidents or burns is often attended 
with a low fever, the reaction being imperfect from the continued 
depressing influence of the cause. The same remark is applicable to 
the case of inflammation from poisons, which are locally irritant, but 
sedative to the system. Even the long operation of cold may so 
depress the vital powers — especially of the heart (§ 75) — that the 
reaction is imperfect, and the fever low; in all these cases the symp- 
tomatic fever is typhoid or adynamic (§ 25,) with weak and unequal 
as well as frequent pulse, varying heat of skin (often with partial 
sweats;) a much furred, or dry and brown tongue; extreme depression 
of strength; low delirium, and other signs of nervous depression. 
These symptoms are indications of a disordered state of the blood 
resembling that induced by morbid poisons (§ 186, 191 ;) and their 



TERMINATIONS. 



297 



occurrence receives an adequate explanation when the want of purifi- 
cation and elimination, from which the blood suffers in its congested 
and imperfectly circulated state, is considered; the evidence of the 
disordered condition is afforded in the altered state of the blood cor- 
puscles, the presence of urea, and signs of incipient decomposition 
which may be discovered in the blood, especially in cases of typhoid 
pneumonia (§ 25.) 

444. In the lower forms of inflammation (§ 442,) the fever may be 
remittent or even intermittent: a state of depression alternating with 
a state of excitement, ending with perspiration ; and when inflamma- 
tion becomes chronic, or is of slight character, it may excite no fever 
at all. It generally, however, induces some constitutional disorder, 
in which defective excretion (§ 171) is an important element. When 
it is borne in mind that inflammation includes in itself determination 
of blood, it will be obvious that, besides the irritation connected with 
it, there may be more or less exhaustion of other parts of the body 
(§ 331 :) the part inflamed being over-supplied with blood, other parts 
are in want. This effect is most obvious in anaemic and debilitated 
subjects; and to it must be ascribed the weak circulation, coldness, 
disordered functions, and gradual emaciation of the body in general, 
•which are seen when a part suffers long from low inflammation. The 
blood itself also soon becomes impoverished in continued inflammation, 
losing progressively its proper amount of red corpuscles, and the fibrin 
is deprived of its organizable character, and degenerates into caco- 
plastic or aplastic matter. 

NATURE AND SYMPTOMS OF THE TERMINATIONS OR RESULTS OF 
INFLAMMATION. 

445. The results or events of inflammation may be comprehended 
under four heads: Resolution, Effusion, (including adhesion,) Suppu- 
ration, (including ulceration,) and Grangrene. It must not be sup- 
posed that these often occur quite singly, or that they are separated 
from each other by a very marked line; but these terms are con- 
veniently attached to results in which one or the other predominates. 

Resolution consists in the cessation of the inflammation, and the 
speedy removal of any effusion that may have occurred. As inflam- 
mation consists of determination of blood, with obstruction to its flow 
through some vessels; so the resolution of inflammation consists in 
the yielding of the obstruction and the subsidence of the determina- 
tion, the dilated vessels contracting to their normal dimensions. This 
may be well seen under the microscope. Sometimes nothing remains 
of the inflammation but more or fewer of the white globules adhering 
to the sides of the vessels; but more commonly some vessels are 
observed to be still obstructed, and others congested, with the motion 
in them slower than usual, the determination of blood (enlargement 
of the arteries) having ceased. So, commonly, we find congestion 
remain in a part that has been inflamed; and not unfrequently a flux 
or watery effusion results from that congestion (§ 375.) 



298 



INFLAMMATION — TERMINATIONS. 



446. Resolution of inflammation may occur spontaneously in slight 
cases; or in consequence of treatment; or from the inflammation 
being transferred to another part. Some inflammations creep to 
adjoining parts, as in the case of erysipelas and some other cutaneous 
eruptions. Others affect similar textures in different parts of the 
body ; and being resolved in one part, appear in another: this happens 
in rheumatism, which attacks fibrous textures, and is transferred from 
limb to limb, or joint to joint, by what is called metastasis, or trans- 
lation. This may be fairly traced to the mobility of the peculiar 
materies morbi, (§ 402,) the cause of the inflammation. A remarkable 
metastasis of resolving inflammation is sometimes seen in parotitis, 
the breast or the testicle becoming the seat of the new attack. 

447. The occurrence of resolution is marked by a subsidence of the 
chief symptoms of inflammation: first, of the heat and pain, and, 
more gradually, of the redness and swelling. The heat usually yields 
to perspiration. The pain becomes gradually easier; and in some 
parts, as the skin, may pass into itching before it subsides. The 
redness sometimes simply fades ; more commonly it becomes less florid, 
and may pass through shades of a livid or dusky hue before it vanishes. 
The swelling soon subsides; the effused fluids being so speedily re- 
moved by absorption, that effusion can scarcely be said to have been a 
result. Still, in some instances, congestion, or some of its results 
(§ 274, 350,) or nervous irritation (§ 126, 152,) remains behind after 
the inflammation has ceased. 

448. The resolution of any considerable inflammation is marked by 
a reduction of the fever: the pulse becoming softer and less frequent; 
the skin moist with perspiration, sometimes profuse ; the urine, becoming 
more copious, abounding in urea, and depositing, as it cools, a plenti- 
ful lateritious or branny sediment, consisting of lithate of ammonia. 
The constancy of this last change on the decline of inflammatory 
fever has led to the supposition that it is critical, and determines the 
removal of the disease. The lateritious sediment in the urine is a 
pretty certain symptom of the subsidence of fever, and of the amelio- 
ration at least of the inflammation which excited it; but it is uncertain 
how far it is the cause, or the effect, of the improvement. It indicates 
an increased excretion of the solid constituents of urine; for there is 
often an excess of urea and saline matter as well as of the lithates ; 
and comparing this with the scanty secretion of urine during the 
febrile excitement, and the decay of tissues and blood which is always 
taking place (§ 254,) we can scarcely avoid the conclusion that these 
excrementitious matters had been accumulated in the blood in conse- 
quence of the impaired function of the kidneys during the fever; and 
that now, as the fever subsides, and their function is restored, the 
accumulated matter is thrown off. Now, although the function of the 
kidney must be first impaired to cause the accumulation of the excre- 
mentitious matter in the blood, still the matter so retained tends to 
keep up the disorder (§ 68, 171;) hence it is by remedies, which pro- 
mote the elimination of this matter, that we succeed best in reducing 
febrile excitement. So, likewise, in cases where the function of the 
kidneys is permanently impaired by Bright's disease (congestive de- 



RESULTS — EFFUSION. 299 

generation, (§ 309,) inflammatory and other fevers are not readily 
brought to a termination: persons so affected are said to be "bad 
subjects," .with "broken down constitutions;" and they often sink 
because their excreting organs are unequal to the increased task 
thrown on them. In cases in which the resolution of the inflammation 
is only partial or imperfect, a daily remission or alleviation of the 
fever may take place; and with it there is usually a deposit in the 
urine, of a pinker or lighter colour than the usual brown lateritious 
sediment, and containing, besides lithate of ammonia, purpurate of 
ammonia and lithate of soda. During the resolution of pneumonia 
the chlorides, which had disappeared from the urine, are again secreted 
in increased quantity. 

Effusion {including adhesion.) 

449. Effusion is a frequent result of inflammation (§ 423;) but it is 
not always a termination of the process, like resolution (§ 427.) An 
abundant effusion of liquor sanguinis, of coagulable lymph and serum, 
of pus, or of inflammatory mucus, usually lowers the inflammation- — 
that is, reduces the determination of blood, and it may even diminish 
the obstruction, but often does not remove it; the effused matter then 
causes sundry mischievous effects, by compressing, stuffing, or obstruct- 
ing the several structures in which it accumulates. We may with ad- 
vantage pursue the history of effusions, by tracing the changes they 
cause in the chief elementary tissues. 

Serous membranes, being simple in structure, afford the best preli- 
minary illustration. In acute inflammation in a healthy subject, be- 
sides serum, an exudation of fibrin or coagulable lymph takes place in 
a few hours. This fibrin is at first in a semi-fluid, ductile state ; so 
that the motion or pressure of the inflamed surfaces draws it into the 
bands or threads, which exhibit the same adhesive properties that have 
been spoken of as belonging to one of its constituents, the pale corpus- 
cles, while still within the vessels (§ 417;) or it spreads it into films, 
such as are found on the pleura, pericardium, and peritoneum. But 
if we examine inflamed surfaces which are less exposed to motion or 
pressure, as the looser parts of the auricles of the heart, the serous 
covering of interlobar divisions of the lungs, that of the less projecting 
parts of the intestines, and that of the convolutions of the brain, we 
find the deposit of lymph to be not in a uniform film, but in points con- 
stituting a granular surface ; this shows either that more is effused at 
some points than at others, or that the concretion of fibrin having begun 
in points, has chiefly augmented around the same. The granules thus 
deposited vary in size, from that of a grain of sand to that of a millet- 
seed ; but if the deposit increases, they enlarge into patches, which may 
run into one another, and even form a continuous mammillated coating 
of lymph. Even on surfaces which are subject to motion, the predo- 
minant deposit of the fibrinous effusion at points is shown by a villous 
or shaggy appearance of the lymph : this is caused by the lymph in its 
ductile state, being drawn into threads projecting from the points where 
it has first concreted: this is sometimes well seen on the pericardium. 
On the pleura, these inequalities are more obliterated by the rubbing 
motion of respiration, or by the pressure of liquid effusion. 



300 



INFLAMMATION — RESULTS. 



450. The lymph thus effused is (like the buffj coat of inflammatory 
blood) at first transparent ; afterwards it becomes yellowish, and more 
or less opaque, but in inflammation of a healthy subject it generally 
retains some degree of translucency. In this respect, it contrasts with 
the product of inflammation in unhealthy subjects, (purulent and tu- 
berculous lymph,) which is more opaque. This difference has been 
more fully shown by Mr. Paget to depend on the respective prevalence 
of the fibrinous element in the healthier lymph, and the corpuscular 
element in the opaque and less plastic lymph: and he distinguishes 
especially these varieties as fibrinous and corpuscular. But the most 
important character of healthy lymph is its high susceptibility of or- 
ganization, a character which I propose to designate by the term eu- 
plastic (§ 211.) Euplastic lymph consists of fibrils of fibrin crossing 
each other in various ways, with a moderate intermixture of exudation 
corpuscles, both compound (cells with nuclei and granules) and simple 
(granules and molecules.) Now these fibrils are also found in the buffy 
coat of inflammatory blood (§ 212 ;) and there can, therefore, be no 
doubt that they are identical, and that the blood altered by the inflam- 
matory process is the source of the deposit (§ 438.) This leads us 
to anticipate, what is really the fact, that the plasticity of lymph de- 
pends very much on the good quality of the blood, as well as on the 
energy of the inflammation. Healthy blood, which abounds in red 
corpuscles as well as in fibrin, furnishes the most plastic kind of lymph 
(§ 183 ;) and inflammation, attended with the most active determina- 
tion of blood, (so long as the integrity of the vessels is preserved,) se- 
parates this lymph in the greatest abundance. This lymph already 
possesses living properties, for its materials arrange themselves into 
the basis of a texture: but to sustain the life of this texture, it is ne- 
cessary that due supplies of blood should be furnished, and this is ef- 
fected by the wonderful process of the formation of blood-vessels in it 
which become continuous with those of the adjoining parts. 

451. The precise manner in which vessels are formed in lymph is 
still a matter of some obscurity. Mr, Kiernan has observed inflamed 
capillaries to become varicose, to project at points into pouches and 
diverticula, and to stretch into loops. If such pouches and loops were 
to give way, the blood would be injected into the lymph; and if some- 
thing of the nature of channels had been previously formed by the ar- 
rangement of the fibrils, or by the elongation and communication of 
cells, it is quite conceivable that a current might be produced through 
several openings by the vis a tergo, and that a return of the blood might 
take place in consequence of a reversal of the weaker currents. Mr. 
Travers has noticed a process somewhat resembling this ; he has seen 
solitary red corpuscles make their way into a bed of lymph globules, 
and after for some time exhibiting an oscillating movement, give way 
before a current. The oscillatory movement most probably depends 
on the pulses of the heart, as the analogous motion described in ob- 
structed vessels does (§ 418.) Yogel speaks of new vessels, and even 
of the blood within them, as being directly produced out of the blas- 
tema, independently of previously existing vessels; but if this observa- 
tion were correct, we might expect frequently to meet with the appear- 



EFFUSION — LYMPH — VARIETIES. 



301 



ance of vessels in detached masses of lymph, and throughout the thick- 
ness of the large clots that accumulate on serous membranes. It has 
been ascertained by Schroeder, Liston, and others, that the new vas- 
cular channels are at first much larger than the vessels which supply 
them ; they are afterwards contracted by the formation of a basement 
membrane lined with epithelium ; and the whole texture becomes more 
consistent and less bulky, exhibiting a filamentous and cellular struc- 
ture, with nucleated cells scattered through it. These new membranes 
form patches on, or adhesions between, the serous coverings of the 
lungs, the heart, and the intestines ; and provided they are loose, flexi- 
ble and of moderate thickness, they may cause no disorder. It was 
for a long time considered, in consequence of the frequent formation 
of plastic deposits after inflammation, that this process was really Na- 
ture's plan for repairing injury to structure, but Dr. Macartney has 
shown that this is not the case. He has pointed out that generally the 
powers of repair are in inverse proportion to the tendency to inflam- 
matory action, and that this action retards rather than aids repair. 
Inflammation is only really salutary when there is deficiency of fibrin, 
and therefore of organizable power, in the blood. It then causes the 
supply of the deficient principle. Inflammation renders the plastic 
supply of fibrin more abundant, and hence the filling up of a wound by 
granulations is a more rapid process than the more perfect formation 
of structure that takes place in the absence of inflammation, but the 
temporary deposit has then to be subsequently removed, and more 
highly organized tissue substituted for it. 1 

452. When the subject is unhealthy, when the inflammation is of a 
low character, or when the blood is poor in red corpuscles, or more 
especially when these conditions are combined, the solid products of in- 
flammation are less capable of organization, and therefore may be 
called cacoplastic. Generally the appearance of the lymph when first 
effused gives evidence of its inferior plasticity: it is more opaque, less 
cohesive, and under the microscope, exhibits a predominance of the 
pale corpuscles, with fewer and less regular fibrils. The varieties of 
lymph designated corpuscular by Mr. Paget, and croupous by Prof. 
Rokitansky, are either of this kind or of a still lower degree of or- 
ganization. As the process of organization varies in degree of com- 
pleteness, so these products attain to different stages of perfection, and 
form membranes of a denser, less pliant texture and of less vascularity, 
than the serous membranes to which they are attached, and which they 
therefore shackle. Thus patches of a kind of fibro-ceilular, or fibro- 
cartilaginous membrane, are often formed in the lungs, the heart, and 
the intestines; sometimes with the effect of materially impeding the* 
functions of these several organs. Where the effusion of lymph is 
scanty and slow, its granular mode of deposit is more obvious than in 
more acute disease; for being less ductile, it is less readily spread or 
stretched by the motion of the parts (§ 449.) This is well seen in 
chronic inflammations of the peritoneum and arachnoid membrane, in 
which the deposit is almost entirely in granules or flattened patches, 

1 See Macartney's Treatise on Inflammation, page 7. 



302 INFLAMMATION — RESULTS. 

commonly called tubercles. These are generally of a buff or skin co- 
lour, of firm consistence, and sometimes there are slight traces of blood- 
vessels in them ; x but sometimes their colour is more yellow, they are 
more opaque, their texture is uniform and tough, and they are destitute 
of vascularity. They then constitute the formations described under 
the names cirrhosis and crude yellow tubercle, and are the lowest of 
organized products. Being, in organization and consistency, dissimilar 
to the membranes on which they are formed, they prove a source of 
irritation and constriction ; and being liable to ulterior changes, (shrink- 
ing and contraction in the case of cirrhosis; farther degeneration and 
softening in the case of yellow tubercle,) they may lead to extended 
mischief in contiguous parts. 

453. In some cases, again, more or less of the solid product of in- 
flammation is aplastic, or totally incapable of organization, and is 
thrown off with the liquid, in numerous separate cells filled with gra- 
nules and molecules, constituting pus; or it is deposited in detached 
opaque flakes or curds, consisting of aggregations of irregular granule- 
cells, oil-globules, and molecules, held together by a few fragments of 
fibrils ; the whole pervaded by and contained in serum : such effusions 
are exemplified in the sero-purulent liquid and curdy matter of low 
pleurisy, pericarditis, and peritonitis. It is obvious that such lifeless 
products must act prejudicially on the containing structures; and as 
might be anticipated, they are little susceptible of absorption. 

454. I have mentioned (§ 452) a low form of inflammation, and an 
unhealthy condition of the blood, as causing the cacoplastic character 
of the products of inflammation. It may be added, that the long con- 
tinuance of any inflammation, and its occurrence in subjects in whose 
blood fibrin abounds, while the red corpuscles are scanty (§ 185, 195,) 
will pretty surely render its products cacoplastic or aplastic. At the 
onset of inflammation its products may be plastic, and the process of 
vascular organization (§ 451) may commence; but if the inflammation 
continues, the effusion either is thrown beyond the reach of vascular 
communication, or it displaces that already effused, then the outer layer 
is in a degenerating condition. But besides this, the pressure of the 
effused liquid may impede the construction and injection of the new 
membrane, which therefore degenerates into one of the cacoplastic or 
aplastic matters above described. Again, in scrofulous or cachectic 
subjects, the blood, although scanty in red corpuscles, abounds in fibrin, 
and this is readily effused in inflammation; but it is of low vitality, and 
susceptible of little or no organization. 2 There is yet another circum- 

1 Mr. J. Dalrymple has observed, that the vascularity of lymph may he seen earlier, 
in cachectic and scorbutic, than in healthy subjects. But syphilis and scurvy may mo- 
derate inflammation, without rendering the lymph aplastic: the great impediments to 
organization of lymph are, its bad quality and excessive quantity, and the persistence of 
inflammation. Mr. D. has shown, that even a large coagulum of blood may soon become 
vascular in a scorbutic subject; but it does not follow that either this or lymph in such 
subjects can be formed into real texture. 

2 When a coagulum of fibrin is retained long in a vessel without becoming organized, 
it loses its structure, and softens into an opaque semi-fluid matter, which long was mis- 
taken for pus; but Mr. Gulliver first showed that it consists of much smaller particles, 
mere irregular granules and fatty globules; and in fact that many cases that were for- 
merly considered as inflammation of veins were simply ^examples of this softened fibrin. 



EFFUSION FROM MUCOUS MEMBRANES. 



303 



stance tending to lower the plasticit}' of lymph, although, according to 
the observation of Mr. Dalrymple, it sometimes accelerates its organi- 
zation 1 — that is, the admixture of the colouring matter of the blood 
Vr'ith it. Laennec supposed that contraction of the cavity of the chest 
had its origin in hemorrhagic pleurisy only. This is not correct; but 
I have many times remarked after death, that lymph on the pleura and 
pericardium in cachectic subjects, is much stained with blood; and I 
have found that where patients with similar symptoms have recovered 
from the inflammation, they have been subsequently affected with struc- 
tural disease. It is very probable that in such cases the colouring 
matter is itself diseased (§ 186.) 

455. The more complex structure and nature of mucous membranes 
considerably modify the form and appearance of the products of their 
inflammation. But according to Gerber, Henle, and Gruby, they may 
be seen by the microscope to consist of pus and mucous globules, gra- 
nular cells, granules, and molecules, together with more or less amor- 
phous and glutinous mucus and scales of epithelium. I must add, how- 
ever, that in the early stage serum is present, as is manifest from the 
saline taste and coagulability by heat; and at an advanced stage, the 
mucus acquires a considerable increase of fatty matter. 

Irritation of mucous membranes merely causes a flux (§379,) that is, 
renders the natural mucous secretion more copious, watery, and saline 
than usual, and containing fewer cells. Bat if the irritation be con- 
tinued, and inflammation follows, the secretion is at first diminished by 
the effusion of serum and pale corpuscles into the interstices of the mu- 
cous and submucous texture, and this causes more or less thickening 
or swelling. Soon, however, the effusion overflows to the surface in 
the form of a more or less viscid, saline-tasted liquid, containing glo- 
bules and epithelium scales ; and as the inflammation gets more intense, 
the cells or globules predominate, and the mucus becomes scanty, but 
is still very viscid. On the first decline of the inflammation, the mucous 
and saline matters diminish, whilst the fatty matters increase, and the 
corpuscles compose the chief mass of the secretion, and give it the yel- 
lowish or greenish opacity seen in "concocted" sputa: and this opaque 
matter is afterwards gradually replaced by the natural mucous secre- 
tion. In many cases, especially in young subjects and others in whom 
the inflammation penetrates to the submucous cellular texture, fibri- 
nous matter is thrown out, forming films or shreds of lymph, or giving 
a fibrous or curdy appearance to the mucus, as in croupy inflammation : 
but this fibrin very rarely becomes organized on mucous membranes, 
because their secreting apparatus and secretions lie between the lymph 
effused and the vascular structure. Hence the exudation corpuscles of 
inflammatory mucus are degenerating or aplastic, and constitute the 
opacity of the viscid muco-purulent, purulent, and shreddy fibrinous 

In this state it bears the closest general and microscopical resemblance to mature and 
softened tuberculous matter. It appears to me, that certain softened tuberculous ap- 
pearances, met with in the lymph of serous membranes and parenchymata, are similar in 
their nature. We now know that fibrin and similar matters are prone to a spontaneous 
c inversion into fatty matter, which, appearing in minute globules, disintegrates and 
breaks up the solid into an opaque granular pulp. 
1 Medico-Chirurg. Trans., 1840, p. 212. 



304 



INFLAMMATION — RESULTS. 



matters exuded by inflamed mucous membranes. If inflammation per- 
sists in a mucous membrane, the cells continue to abound in the effu- 
sion, commonly rendering it opaque and purulent; and the natural mu- 
cous secretion being impaired, the product is more diffluent. But in- 
flammation rarely continues long over a great extent of surface ; it is 
confined to patches, which yield their opaque effusion whilst other parts 
may be secreting natural mucus. Hence the mixed appearance of the 
secretions in chronic inflammations of mucous membranes (bronchitis, 
mucous enteritis, and cystitis.) 

Sometimes interstitial effusion, which takes place at the commence- 
ment of inflammation of a mucous membrane, is not entirely removed 
by the subsequent discharge. In such cases there may remain a per- 
manent thickening of the mucous and submucous texture; this is the 
cause of the indurations and strictures which inflammation sometimes 
leaves in the intestines and urethra ; and to a less degree in the air- 
passages. This, however, it must be observed, is the result of inflam- 
mation of the submucous cellular texture rather than of the mucous 
membrane itself. 

456. Inflammation of the shin presents great variety as to the amount 
and kind of its products. The full consideration of these would lead 
us into the pathology of skin diseases, a subject replete with interest 
and practical importance, although sadly neglected amidst the artificial 
distinctions of writers on cutaneous disorders; but the subject is too 
wide to be discussed here. 

Some of the effusions in and from the skin have been glanced at 
under the head of the symptoms of inflammation (§ 432.) It may now 
be added, that these effusions may consist of clear serum, with few exu- 
dation corpuscles and molecules, as in the liquid of blisters and blebs, 
and of eczema, which dries into thin scabs ; or of milky serum more 
abounding in the corpuscles/which dry into thicker scabs, as in herpes, 
rupia simplex, &c. ; or of liquor sanguinis and purulent serum, with 
more numerous corpuscles, which form very thick yellow or brown scabs, 
as in rupia prominens, impetigo, and ecthyma: or the effusions may be 
chiefly solid, and thrown into the substance of the true skin, as in tu- 
bercular inflammations and incipient pustules. In all cases of inflam- 
mation of the skin, there is an increased production of epidermis, which 
is sometimes thrown off in scales with the scabs ; or in a peeling of the 
cuticle; or it thickens, and forms a hard covering, liable to clefts and 
sore ulcerations, as in psoriasis, inveterate eczema, &c. 

457. Inflammatory effusion into the cellular texture consists of serum, 
with more or less of the exudation corpuscles and fibrin. In diffuse 
erysipelas or cellulitis, the fibrin is deficient, and the corpuscles either 
are in moderate numbers, or else they are degenerative (purulent.) In 
phlegmonous inflammation there is more fibrin, which circumscribes 
the effusion, and causes a harder swelling; and the pressure of this, 
with a continuance of inflammation, sometimes leads to suppuration or 
sloughing. 

458. Effusions from inflammation of parenchymatous organs re- 
semble those from inflammation of cellular texture ; but the parenchy- 
mata in general being very vascular, as well as yielding, the solid effu- 



EFFUSION IX CELLULAR TEXTURES, ETC. 



305 



sion may be very copious, and jet not cause the pressure or tension 
that leads to suppuration and gangrene. The lymph effused exhibits, 
in regard to plasticity, the same varieties which we have described in 
the products of serous membranes, (450, et seq.) But inasmuch as 
lymph effused in the parenchyma of an organ would greatly interfere 
with its function, we rarely find it organized, except in limited por- 
tions, which thus remain solid and dense. More usually the matter 
deposited is gradually removed by absorption or secretion after the in- 
flammation declines; or if the inflammation continues, the exudation 
globules and lymph are converted into, or replaced by, various kinds 
of pus or tuberculous matter — consisting of degenerated corpuscles, 
granules, and fatty globules. 

459. Effusion so closely attends the process of inflammation, that 
the symptoms of effusion have been comprehended in those of inflam- 
mation. Swelling, pressure, obstruction, irritation, consolidation, dis- 
placement, and various functional, as well as structural disorders, may 
arise from the presence of effused matter. Hence the occurrence of 
effusion may aggravate some of the symptoms of inflammation, whilst 
others may be more or less relieved by it. Where a copious effusion 
takes place, the pain, heat, redness, and fever, are commonly reduced: 
for the vascular and nervous excitement and determination of blood 
are thereby lessened; but the local or visceral disorder may be in- 
creased. The pulse may be as frequent, but it is less hard and full ; 
the fever less constant, but it may continue in a lower degree, or as- 
sume a remittent or hectic form. The relief by effusion is greatest in 
slight inflammations, or where the effused matter can be thrown off 
from the body, as in the case of mucous membranes; but there may be 
much irritation and exhaustion of strength caused by the process of 
throwing it off, (as in cough and expectoration, diarrhoea, purulent 
micturition, &c. ;) and these will be more harassing where, as is some- 
times the case, the effusion does not remove the inflammation. 

Suppuration and Ulceration. 

460. The formation of pus among the products of inflammation has 
been several times noticed (§ 424, 453, 455, 457, 458.) Pus is an 
opaque greenish or yellowish white liquid, of creamy consistence, little 
odour, and of specific gravity varying from 1030 to 1033. It is chemi- 
cally composed of water, deutoxide of protein forming the cell walls, 
tritoxide of protein and albumen in solution, fat, extractive matter, 
and the same salts as those in the blood. Recently formed pus con- 
tains more albumen and fat than is found in the liquor sanguinis ; but 
according to Gerber, mature pus contains more fat and less albumen 
than that recently formed. 

Microscopically, pus is seen to consist of a limpid serum, and very 
numerous globules of pretty regular size and form. These globules 
have much resemblance to granular cells or exudation corpuscles 1 (§ 

1 Mr. Paget has also pointed out the close analogy between the granular corpuscle and 
pus-cell: in fact, he considers the latter to result from the degeneration and partial 
liquefaction of the former (Lectures, vol. i., p. 231,) -which nearly accords with the views 
previously expressed in this work. 

20 



306 INFLAMMATION — RESULTS. 

424,) but they are more opaque and are more distinctly and constantly 
provided with a cell wall and nucleus, in addition to granules and mole- 
cules. "Vogel describes their form to be in general spherical ; but some- 
times irregularly rounded or oval: their cell wall is commonly opaque, 
and somewhat uneven from being studded with minute granules ; so 
that their contents may not be apparent without the addition of acetic 
acid, which renders the walls transparent, and brings into view their 
nuclei, which then take the form of from one to five somewhat elliptic 
disc-shaped bodies clustered together and attached to the interior of 
the cell. The existence of the cell in most pus globules is also made 
clear by the action of distilled water, which causes the cell to dilate 
(by osmosis) to double its former size ; the larger granules or nuclei 
swell also, and this shows their vesicular nature. According to Mr. 
Gulliver, they measure on an average ^j^ih of an inch in diameter. 1 
They commonly differ from the exudation corpuscles also in being more 
distinctly vesicular, and containing a fluid, as well as granules : they 
more readily swell, burst, and shed their contents under the influence 
of water or potass (Addison.) In some instances, Vogel admits pus 
globules to be devoid of a distinct cell wall; this I have stated to be 
the case with some of the white or granular corpuscles, and the only 
distinction of this kind of pus globules is found in its exhibiting a pe- 
culiar trefoil or cordiform nucleus under the action of acetic acid. 

461. Another distinguishing character of the pus globules is their 
want of cohesion; hence in proportion as they predominate, they 
impair the consistence of fibrin or mucus with which they may be 
mixed. In this, respect they contrast remarkably with the white cor- 
puscles, which both within and without the blood-vessels manifest a 
remarkably adhesive and cohesive property. This and the other dif- 
ferences may be all explained on the supposition that the more gela- 
tinous or semi-solid parts become completely fluid in the pus globule, 
whilst the cyst becomes more solid, and tougher than before : such a 
change would account for the vesicular form and incohesive properties 
of the globules of pus ; and the extension of a similar change to the 
larger of the contained granules, would equally convert them into 
minute cells, which have the appearance of nuclei, with the usual 
osmotic properties. This liquefaction accompanying the formation of 
pus, is not confined to the contents of the pus globule, nor even to 
the plasma, lymph, and other products of inflammation; it extends to 
the containing vessels and textures, which are softened, disintegrated, 
and removed, in proportion as the suppurative process proceeds. In 
complex textures, therefore, whence the pus cannot escape, this process 
consists not merely in the formation of pus, but also in its substitution 
for more or less of the inflamed texture: for this reason, suppuration, 
more than effusion, may be called a termination of inflammation, for 
the inflamed vessels are in great part destroyed. 

1 Pus is not commonly produced in birds or in cold-blooded animals: the reason of 
this is not understood, as the exudation corpuscles do not materially differ from those of 
mammalia, although the red corpuscles are oval. In the camelidse also, in ^vhich the 
red corpuscles are oval, the pale corpuscles and pus globules are round. — Gulliver; Med. 
Chir. Trans. 1839, and Phil. Mag., 1842. 



SUPPURATION — CAUSES. 307 

The chemical change which accompanies and probably causes this 
disintegration and liquefaction in the formation of pus, seems, according 
to the researches of Mulder, to be an increased oxidation of the 
protein, whereby it passes from the state of a solid deutoxide into that 
of a tritoxide, which is readily soluble in water or serum. Bat this 
further oxidation and solution implies also a reduction of vitality in 
the exuded corpuscles, which thus lose their organizing power, and 
degenerate into a loose aplastic material. Probably in some instances 
the corpuscles are originally defective in organizing power, and are 
therefore prone to degenerate; whilst in others they become so from 
defective nutrition or from some interruption to their plastic power. 
We shall find that the circumstances which promote suppuration, the 
nature of the process, and the symptoms which accompany it, exactly 
correspond with this view of the subject. 

462. The circumstances which determine suppuration as a result of 
inflammation, are chiefly three: — 1. A certain intensity and duration 
of the inflammation; 2. The access of air to the part; 3. A peculiar 
condition of the blood. 

1. Intensity and continuance of inflammation comprise the persis- 
♦ tence of the two chief elements in the process, determination of blood 

and obstruction (§ 419 ;) and as we have seen, that the physico-chemi- 
cal effect of these is the first to direct the force and to exaggerate the 
influence of the red corpuscles (which convey oxygen,) on the liquor 
sanguinis, so that more of its protein passes into the state of solid deu- 
toxide — a material fitted for organization and reparation: — so we may 
infer that the excessive degree or continuance of the same action may 
overdo the change, give chemical properties an ascendency over the 
vital powers ; and by turning the most recently formed solid into a 
fluid tritoxide, it may effect a work of separation and destruction, in- 
volving the blood in the obstructed vessels, and extending to the albu- 
minous matter of the containing texture. Such a result is most likely 
to ensue in complex and highly vascular structures, in which the ef- 
fused matter is retained in intimate contact with the blood-vessels: 
hence intensity and continuance of inflammation in the true skin, cel- 
lular textures, glands, and most parenchymatous organs, pretty surely 
lead to suppuration. In serous and fibrous membranes, on the other 
hand, suppuration is a rarer result, because the vessels are few, and 
the effused corpuscles placed less within their influence. In partial 
external inflammations, suppuration may often be prevented by pres- 
sure, which acts by diminishing the determination of blood, and there- 
fore by reducing the oxygenating influence. 

2. The access of air to a wound or to a serous membrane is well 
known to promote the formation of pus ; and it may do so mainly by 
directly supplying oxygen, and converting the fibrin, and part of the 
exudation corpuscles, into the soluble tritoxide of protein ; but air may 
also operate as an irritant to a serous membrane or abraded surface, 
increasing the intensity of the inflammation, and promoting the de- 
generation of its products. A limited access of air to a large quantity 
of pus leads to a decomposition of the matter and the production of 
sulphuretted hydrogen, which acts as a deleterious poison on living 
structures. 



308 



INFLAMMATION — RESULTS. 



3. That a peculiar condition of the blood promotes the occurrence 
of suppuration after inflammation is obvious from the readiness with 
which all wounds, scratches, and pimples then fester, and with which 
inflammations of no peculiar intensity lead to the early formation of 
pus in different structures. This state of the system constitutes what 
has been called the suppurative diathesis, and is presented in cachectic 
or ill-conditioned subjects, the quality of whose blood has been injured 
by mal-nutrition, imperfect excretion (§ 171, 187,) or by the direct 
operation of some morbid poison (§ 258, 296} such as that of erysipelas, 
confluent small-pox, glanders, &c. Mr. Paget found on examining the 
fluid exuded in blisters raised by cantharides plasters applied to the 
skin, a variety of products illustrating the difference in the products 
of inflammation resulting from constitutional causes. "Thus, in cases 
of purely local disease, in patients otherwise sound, the lymph thus ob- 
tained formed an almost unmixed coagulum, in which, when the fluid 
was pressed out, the fibrinous, firm, elastic, and apparently filamentous 
masses at the opposite end of the scale, such as those of advanced 
phthisis, a minimum of fibrin was concealed by the crowds of cor- 
puscles imbedded in it. Between these were numerous intermediate 
conditions which* it is not necessary now to particularize. It may 
suffice to say, that after some practice, one might form a fair opinion 
of the degree in which a patient w r as cachectic, and of the degree in 
which an inflammation in him would tend to the adhesive or the sup- 
purative character, by these exudations. The highest health is marked 
by an exudation containing the most perfect and unmixed fibrin ; the 
lowest, by the formation of the most abundant corpuscles, and their 
nearest approach, even in their earliest state, to the character of pus 
cells. The degrees of deviation from general health are marked either 
by increasing abundance of the corpuscles, their gradual predominance 
over the fibrin, and their gradual approach to the character of pus 
cells ; or else, by the gradual deterioration of fibrin, in which, from 
being clear, elastic, tough, and uniform, and of filamentous appearance, 
or filamentous structure, it becomes less and less filamentous, softer, 
more paste-like, turbid, nebulous, dotted, and mingled with minute oil 
molecules." — (Lectures, vol. i., p. 338.) 

But the most efficient cause of the suppurative diathesis is the abun- 
dant presence of pus itself in the blood (pyaemia,) as occurs in cases 
of phlebitis, diffused suppuration, &c. ; and indeed it is most probable 
that this cause really exists in the examples above mentioned also; for 
Mr. Gulliver and others have detected pus globules in the blood in 
many such cases (although this has been denied by Lebert and Roki- 
tansky ;) and there is good ground to suppose that in all cases of sup- 
puration some of the granular corpuscles are converted into pus glo- 
bules within as well as without the vessels ; but for reasons that will 
afterwards be explained, this takes place only to a very limited extent 
under ordinary circumstances. The conversion of the white or exuda- 
tion corpuscle into the pus globule always implies a lowering of vitality; 
and therefore a peculiar proneness to the change (independently of in- 
tensity of inflammation and exposure to air) indicates a feeble state of 
the vital powers, rendering them unequal to resist chemical affinities. 



SUPPURATION — NATURE OF THE PROCESS. 



309 



In extreme cases this tendency shows itself by the occurrence of gan- 
grene, which often supervenes in the worst form of pyaemia, as in ma- 
lignant erysipelas and phlegmon. It is therefore quite intelligible 
that pus, when present either in a part, or in the blood at large, may 
act in the mode of a chemical ferment, promoting the formation of 
more like to itself, and tending to degrade the plasma of the blood 
from that organizable condition in which it can repair breaches or sus- 
tain the nourishment of the body. This inference seems warranted by 
numerous chemical facts, although microscopical observers do not agree 
as to the fact of the constant presence of pus-cells in the blood. In 
all probability the infection in pyaemia may be from the liquor puris 
as well as from the pus-cell itself; this appears to be the opinion of 
Rokitansky. 

These considerations will throw much light on the further process 
and symptoms of suppuration. 

463. The process of suppuration strongly illustrates the opposite 
character of the elements of inflammation before alluded to (§ 421.) 
The obstruction to the passage of the blood through the capillary ves- 
sels of an inflamed part, and the increase of this obstruction by the 
pressure of material effused by those vessels that are the seat of deter- 
mination, reduce the vitality of the tissue to so low a degree, that they 
are unable to withstand the chemical power of the effused fluids, 1 acting 
as solvents, and exalted as it is by high temperature. The textures 
are therefore gradually disintegrated, dissolved, 2 and absorbed away, 
whilst the exudation corpuscles degenerating and softening into pus-cells, 
occupy their place, and continue to be effused and developed by the 
vessels which are still the seat of determination of blood. 3 This assumes 
that absorption is still active in an inflamed part; and the assumption 
is warranted by the fact, that the absorbed vessels, veins and lacteals, 
remain perfectly free : the very occurrence of increased pulsation and 
flow in communicating and contiguous vessels (§ 413,) will promote the 
exosmosis of fluid matter by the absorbent vessels. That the pus glo- 
bules should remain unabsorbed will not appear extraordinary, when 
their size is taken into account (§ 460,) and also the fact that their 
cysts are not dissolved by their proper fluid, having acquired a remark- 
able degree of toughness. Their large size is wholly opposed to the 
notion that they are effused from the blood-vessels as pus-globules; but 

1 That the liquid of pus can chemically dissolve dead animal matter was proved by J. 
Hunter, who found that pieces of raw meat were dissolved in abscesses, or even in pus 
kept warm out of the body. The experiments of Sir C. Wintringham show that other 
animal fluids have a like property. Dr. Prout notices similar facts. This solvent pro- 
perty we have now reason to ascribe chiefly to the formation of the soluble tritoxide of 
protein. A similar change takes place during the cooking of meat; so that the old ex- 
pression concocted matter is not altogether metaphorical. Nor is the familiar term of 
ripening of an abscess derived from an analogy wholly imaginative. The ripening of fruit 
and other vegetables depends on a spontaneous liquefaction of parts previously solid 
having a resemblance both chemical and histological to the process of suppuration. 

2 The idea that the removal of textures in suppuration is owing to their death origi- 
nated with Dr. Billing. (See his "Principles of Medicine.") 

3 That absorption is increased in an inflamed part is further proved by a direct obser- 
vation of Kaltenbrunner, who watched the gradual disappearance of the pigment spots 
in the frog's web. This, however, was not the result of suppuration, as that process 
does not occur in cold-blooded animals. 



310 



INFLAMMATION — RESULTS. 



their arising from the exudation granules and cells easily accounts for 
their appearance in the midst of lymph, and other products of inflam- 
mation, which they supersede as they enlarge and multiply. Thus the 
combination of apparently opposite results, which has been considered 
so inexplicable, — excited and lowered action, increased secretion, and 
increased absorption — admits of an explanation that is in exact accord- 
ance with all the observed phenomena. 

464. The amount and extent of the process of suppuration varies in 
different cases. In cellular and parenchymatous textures it sometimes 
occurs as purulent infiltration, not circumscribed by lymph, but leaving 
the texture much softened, and partially removed. This diffused kind 
of suppuration is to be referred either to the porous nature of the organ 
(as with the lungs) not admitting an effusion of lymph sufficient to limit 
the suppuration, or to a purulent diathesis or disposition in the blood 
(§ 462.) In most cases, the process of suppuration is limited by solid 
effusion, which may be either the remains of the earlier product of the 
inflammation, or it may be thrown out expressly for the purpose of de- 
fending the adjoining structure from the operation of the pus, obviously 
so noxious a matter. A collection of pus thus circumscribed is called 
an abscess; and when mature, it represents the perfection of suppura- 
tion. The blood-vessels of the inflamed part are destroyed like other 
textures: but their supplying trunks are obstructed by lymph; whilst 
the adjoining capillaries remain pervious, become dilated and varicose 
on the walls of the abscess, (which are composed of layers of organized 
lymph,) and continue to secrete pus; hence this lining is called the 
pyogenic membrane. As the pus increases in quantity, the abscess be- 
comes enlarged, generally towards some cutaneous or mucous surface, 
where it is said to point : the skin or covering membrane ulcerates, and 
the pus is discharged. The direction, which the abscess takes, seems 
to be that in which there is least resistance: the parts there are more 
stretched than in other places; and from being stretched, their vessels 
get more obstructed, so that they cannot maintain the vitality, nor 
throw out the same amount of protecting lymph, which limits the ex- 
tension of the abscess in other directions. Fibrous and other hard 
textures resist the progress of abscesses and the escape of pus. Serous 
membranes, in consequence of their proneness to become plastic at their 
surfaces, first adhere together, and then often give passage to the con- 
tents of an abscess through the adherent layers, without allowing any 
pus to escape into the interior of the sac. In this manner abscesses 
of the liver and kidney make their way across the peritoneum into the 
intestines, through the walls of the abdomen, and even through the 
diaphragm, pleura, and lungs. Where pus does make its way from an 
abscess into a serous sac, it causes severe irritation, and commonly 
fatal inflammation. 

465. After an abscess has opened, it may continue to discharge pus, 
pure, or diluted with serum or sanies; but in healthy subjects, a pro- 
cess of healing takes place by an increased effusion of lymph, through- 
out the interior of the abscess, and the growth of new vessels in this 
lymph in the form of granulations. Pus is still formed by the dege- 
neration of the superficial layer of exudation corpuscles ; and a free vent 



SUPPURATION — ABSCESS — ULCERATION. 311 

must be given to this pus until the growth of the granulations and the 
contractions of the walls shall have obliterated the cavity of the ab- 
scess, and left no more room for the pus to accumulate. 

466. Ulpers sometimes arise from abscesses: an abscess that has 
discharged its contents is, in fact, an ulcer. But more commonly, ul- 
cers originate from limited inflammations of the skin or mucous mem- 
branes, in which the natural cohesion of the tissue is so" much impaired 
by the solvent action of the effusion on it, that it is broken up at one 
or more spots, and: is either carried away in the pus discharged, or is 
absorbed. There is then left a solution of continuity or excavation, 
the bottom and edges of which continue to discharge pus, or a serous 
fluid mixed with exudation corpuscles, and sometimes blood corpuscles. 
Ulcers may tend to spread by the same process as that which forms 
them at first; or to heal in consequence of the effusion of fibrin on their 
walls and the extension of vessels into this in the form of granulations, 
which are then the materials of the new texture. Ulcers however pre- 
sent a great diversity of character as regards the nature of their se- 
cretion, and the condition of their walls, as well as regards the symp- 
toms which they produce : these circumstances are considered in sur- 
gical works. 

The cause of ulceration is commonly local ; inflammation suspends 
the normal nutrition of a structure, and leads to its solution. (§ 460, 3.) 
Ulceration is often preceded by induration from solid deposit ; and the 
ulceration commences in the centre of the induration, because the nu- 
trient influence of the vessels is most reduced by the pressure at that 
spot. But a very poor condition of the blood (hypinosis, § 196) is often 
concerned in determining this result, and seems to be sometimes suffi- 
cient to cause ulceration without any distinct previous induration ; or 
even inflammation ; the parts that suffer being either those which have 
become congested by posture (as occurs in cachectic ulcerations of the 
legs,) or those most remote from the nourishing influence of the blood 
(such as the non-vascular textures, the cornea, cellular parts of carti- 
lages, &c.) Ulcers of this description arise in cases of extreme anae- 
mia (§ 268,) where the fibrin and the albumen of the blood are very 
defective (§ 197,) and are then to be counteracted by measures the 
very opposite to antiphlogistic. A similar result was found, by Ma- 
gendie, to ensue in animals fed on sugar, starch, and other non-azotized 
articles of food. In these instances the ulceration and destruction of 
textures may be referred to the solvent powers of the oxygen of the 
blood being exerted on materials whose vital powers of resistance (§ 16 ) 
have been much reduced, and when there is no supply for their reno- 
vation in the plasma of the blood. 

467. Softening of textures may arise from the same process which, 
when acting in a greater degree, and in more circumscribed space, 
causes ulceration. It has already been spoken of as one of the effects 
of inflammation (§ 427 ;) and it may now be added, that the condi- 
tion of the blood which disposes to ulceration sometimes leads to the 
more diffused operation of the same change in the softening of tex- 
tures. Thus softening of the brain, liver, muscle, and mucous mem- 
brane, sometimes results from ansemia, or imperfect supply of blood 



312 



INFLAMMATION — RESULTS. 



to these parts, or from spanogmia or impoverished condition of the blood 
supplied (§ 1 97 ;) and inflammation, which impairs or deranges the sup- 
ply, may immediately determine the occurrence of the softening pro- 
cess. 

Local Symptoms of Suppuration. 

468. It may be gathered from the previous statements, that suppu- 
ration is a work of destruction, and is therefore, in some measure, to be 
contrasted with effusion of lymph, which is intended to be a process of 
construction or reparation. Pus is totally aplastic itself ; it is formed 
at the expense of the plastic product of the vessels, and the liquid of 
pus seems to act as a solvent or septic on textures whose vitality has 
been reduced. Although, therefore, suppuration is often useful by ter- 
minating inflammation, and by removing superfluous products, and 
parts that have been injured by it or its causes, yet suppuration must 
on the whole be viewed as a depressing and exhausting process, and its 
product as having a noxious character : the symptoms which accompa- 
ny it will be found to correspond with this view. 

469. The occurrence of suppuration is marked by a diminution of 
the heat, pain, and of the other signs of irritation and increased action 
in the part. The pain often becomes throbbing, as if the external 
pressure on some of the larger vessels had momentarily yielded, and they 
had become expanded at each pulsation. The swelling gets softer ; and 
if within the reach of touch, may be felt to be first more yielding under 
the finger, and afterwards to present the fluctuation of fluid matter. 
The redness present in inflammation is also diminished, being wholly 
superseded by the pale yellow of purulent effusion in the central parts 
of the suppurating mass, being mottled by it in others, and retaining 
its deep character only in those circumferential parts to which the sup- 
puration has not reached. In external inflammations, the redness of 
the skin becomes deeper before suppuration; but when this process 
reaches the skin, a pale spot is seen, which by its fluctuating feel indi- 
cates the approach of the abscess to the surface. 

The great reason why the symptoms of inflammation are alleviated, 
on the occurrence of suppuration, is that the tension and hard swelling, 
which chiefly cause the pain and irritation (§ 433,) are diminished ; for 
where suppuration takes place amidst unyielding parts, as under a 
fascia, or within a bone, the tension is increased rather than lessened, 
and then the symptoms of pain and irritation are often more severe 
than ever. The powerful influence of hydraulic pressure in causing 
the injection of a liquid into a compact texture, and the swelling of the 
pus globules by osmosis or cell secretion after their first formation, will 
assist in explaining the effusion of pus under a dense periosteum or 
theca, and the extreme pain and irritation which this produces. The 
free secretion of pus from mucous membranes relieves inflammation, 
and removes the submucous deposit (§ 455.) 

General Symptoms of Suppuration. 

470. The influence of suppuration on the system is manifest in the 
lowering of the inflammatory fever; the pulse loses its strength, but 
retains its frequency ; the heat subsides, or alternates with chills and 



SUrPUHATION — SYMPTOMS. 



313 



sweats ; the general redness is succeeded by paleness, or a hectic flush ; 
the urine deposits a pale or pinkish sediment; 1 and the general excite- 
ment gives place to weakness and exhaustion. The amount of this 
change greatly depends on the extent of the suppuration, and the im- 
portance of the organ affected; but another circumstance that modifies 
the effect of suppuration, and that proves the noxious influence of pus 
on the system, is the difference as to whether the suppuration is dif- 
fused without a circumscribing barrier of lymph, and whether it is thus 
limited, or whether its product is thrown off at once from the body. 

In some cases of inflammation of the cellular texture, skin, and serous 
membranes, pus is formed with little or no previous exudation of lymph, 
and produces in the system the most formidable effects. The pulse 
becomes very frequent and weak ; the tongue brown and dry, or coated 
with an offensive fur, and tremulous; sweats break out profusely; the 
urine is scanty, high-coloured, and fetid, or sometimes even suppressed ; 
a putrid diarrhoea occasionally occurs; hiccup and subsultus come on; 
the mind is much depressed, or excited by occasional delirium ; the pa- 
tient's manner and motions are agitated and restless; the breathing 
becomes hurried and sighing ; and death may ensue in from one to four 
days from the commencement of these symptoms. Similar results 
ensue in suppurative inflammation of veins; and in injuries of the head 
ending in suppuration, that involves communication with some of the 
venous sinuses ; they have also been known to follow, where an external 
abscess has suddenly subsided without opening, and in cases in which 
the discharge from a large suppurating wound has suddenly ceased. 
On opening the body after death, in a few such cases, nothing peculiar 
has been found, except a general fluidity of the blood, and the gravi- 
tative congestions and stains which that fluidity induces (§ 196.) In 
most instances, however, there are found in some of the viscera, parti- 
cularly the lungs and liver, purulent deposits, as they are called ; col- 
lections of pus, generally confined to lobules or portions of lobes of 
these viscera, with more or less inflammatory injection and a scanty 
deposition of lymph around the collections. In these cases, there can 
be little doubt that pus or its serum has been in some way conveyed 
in the circulation ; and then been arrested in the lungs and liver, lead- 
ing to the formation of more like itself (§ 462,) sometimes by the pro- 
duction of local suppurative phlebitis, as supposed by Cruveilhier, 
Dance, and others ; and sometimes by a contamination of the blood 
itself; and thus the pus in the blood is the proximate cause of the en- 
tire train of formidable symptoms and results. In several such cases 
purulent matter has been detected in the blood in considerable quanti- 
ties, not only by the aid of the microscope, but in consequence of the 
pus globules forming a visible layer on the surface of the red corpuscles. 
The experiments of M. D'Arcet, 2 make it seem probable that the poi- 
sonous influence of purulent matter arises from the chemical changes 

1 The occurrence of urinary sediments after suppuration has been noticed by Schonlein 
as a constant phenomenon; but such sediments are also observed after inflammation 
without suppuration, and must be regarded as the debris of plastic matter, and of tex- 
tures that have been wasted during the inflammatory process. 

2 "Recherches sur les Absces Multiples," &c. ; and Brit, and For. Med. Rev. Jan. 
1843. 



314 



INFLAMMATION — RESULTS. 



that are induced by air in its serosity (§ 460 ;) but that obstruction to 
the circulation in the lungs and liver, and consequent circumscribed 
inflammations of these organs, result from aggregation of masses of 
the debris of the pus globules contained in the blood ; it has, however, 
been found by Mi Lebert, and Mr. H. Lee, that the serum of pus in- 
jected into the veins of the more delicate animals, induced the fatal 
results of purulent infection almost as soon as when pus was injected 
entire. 

In instances of the abundant presence of pus in the blood, it is not 
to be supposed that it is absorbed through the entire walls of blood- 
vessels; the large size of the pus globule, as before noticed (§463) for- 
bids such supposition ; but unusual channels of entry into the vessels 
have been in several cases discovered, as in the instance above alluded 
to of an abscess in the skull opening into one of the sinuses ; to which 
it may be added that in suppuration in bones generally, the pus may 
find an easy entrance through the open venous canals; and in wounds 
of the neck it may be drawn in through the large divided veins under 
the suction influence of inspiration. Suppurative phlebitis has been 
already mentioned as an obvious cause of pyaemia. But we must 
again advert to the fact, first established by Mr. Gulliver, that pus glo- 
bules appear in the blood in other cases of severe inflammation and sup- 
puration where no opening into the veins is known to exist. In these 
instances, as before stated (§ 463,) the pus globules are probably formed 
within the vessels of the inflamed part ; and these increase and produce 
symptoms of pyaemia only in cases in which the vitality of the blood 
is impaired, and in which there is a proneness to the formation of pus 
from trivial causes (§ 462.) To this group of cases I would refer se- 
veral instances of pyaemia with the bad symptoms before mentioned, 
which I have seen after scarlatina, and in a few cases of acute albu- 
minuria and typhoid rheumatic fever. Probably, too, malignant ery- 
sipelas and metroperitonitis belong to this class. 

471. The preceding observations prepare us for the fact that ex- 
tensive local suppurations cause various symptoms of depression or low 
irritation, besides the effects specified above. Of this kind are the ri- 
gors often experienced at the commencement or increase of suppura- 
tion. Dr. Billing plausibly ascribes this to the system sympathizing 
at the death of the part which is under destruction by the suppura- 
ting process ; but the rigor not always occurring, suggests rather that 
the presence of a certain amount of pus in the blood may be its cause ; 
this may induce the shivering merely as a depressing agent, or proba- 
bly by directly interrupting the calorific process by the withdrawal of 
a portion of the oxygen, which is essential to its sustenance (§ 461.) 
This latter notion is countenanced by the remarkable and sudden fall 
of temperature which often accompanies the extensive formation of pus. 

Again, when suppuration continues long, even if it be discharged 
outwardly, as in extensive wounds, or ulcerations of the skin or mu- 
cous membranes, there is great wasting of strength and flesh, with a 
partial febrile irritation of a peculiar kind, called hectic fever. This 
is remittent in its symptoms, the exacerbations recurring once or twice 
daily, beginning with chills and depression, and being followed by a fre- 



G A NG R E N E — CAU SBS. 



315 



quent pulse, partial heats, especially of the cheeks, hands, and feet, 
and ending in a profuse perspiration. As this proceeds, the body more 
or less rapidly wastes, and the colliquative sweats and diarrhoea, vo- 
miting, and aphthae of the mouth, are so many proofs of the rapid de- 
composition and removal of the various structures, which tend to hasten 
the fatal result. The febrile part of hectic is most observed in the 
young and irritable ; but the depressing and exhausting effect of ex- 
tensive suppuration is illustrated in all cases, by progressive emaciation 
and cachectic pallidity of a peculiar sallow or stony hue. 

472. The matter of abscesses is laudable or healthy in proportion 
as it is thick and opaque, uniformly liquid, and free from smell; for 
although, even in this state, it is fit only to be expelled from the body, 
and is prone to decomposition, yet if excluded from the air it will re- 
main unaltered for a long time. The formation of such pus is pretty 
sure to be attended with a protection of lymph, and it is far less nox- 
ious than ill-conditioned sanious matter, the fcetor of which indicates 
that decomposition has already begun. 

GANGRENE. 

473. Gangrene, like the more complete forms of suppuration, may- 
be well called a termination of inflammation, for the inflammation ends 
in the death of the part. In suppuration, the dying textures are softened 
and displaced by pus as fast as they die ; in gangrene, the textures die 
more extensively than pus is formed, and they run into decomposition 
without being removed. In some cases, especially in limited gangrene, 
the dead portion is dissolved aw T ay at its circumference by the inflamma- 
tory exudation from the living parts, the activity of which is evinced 
by red vascularity at the line of disjunction ; and the dead part is thus 
separated or sloughed from them ; but if it be extensive, and the 
power of the living parts low, the separating process will not be ac- 
complished before decomposition ensues, and this produces the appear- 
ances known as gangrene and sphacelus. 

4i74t. The circumstances which cause inflammation to terminate in gan- 
grene are, — the complete suspension of the circulation of the part (§ 273,) 
great injury to the composition of the blood, or the direct destruction 
of its vital properties. The circulation of a part may be destroyed by 
long-continued pressure, by severe contusion, laceration, or other me- 
chanical injury, by extreme heat or cold, by strong chemical agents, 
by the excessive pressure of the solid matter effused in the early stage 
of inflammation, (as in carbuncle,) and even by an extreme amount of 
congestion. 1 The occurrence of gangrene is favoured by an extreme 
weakness of the heart, the great moving power of the circulation ; and 
is then most likely to happen in parts that are most remote from the 
heart, as is illustrated in various structural diseases of the organ, in low 
fevers, and states of extreme exhaustion. It is also favoured by ossi- 
fication, or partial obstructions of the supplying arteries, which, al- 
though adequate to maintain the ordinary nutrition of the part, can- 
not dilate to supply the increased demand, should any injury or irrita- 

1 Two cases of gangrene of the lung which have occurred in my practice seemed refer- 
able to this cause. 



316 



INFLAMMATION — RESULTS, 



tion take place. The agents, which cause gangrene by directly de- 
stroying the vital properties of the solids and fluids of the body, are 
various strong poisons, such as arsenic, sulphuretted hydrogen, the poi- 
son of the rattlesnake and other venomous animals, the poison of the 
plague, malignant scarlatina, small-pox, and erysipelas, glanders, kc. 
Various debilitating or noxious influences operating on the body may 
give a gangrenous tendency to inflammations from wounds, and injuries 
of any kind arising from accidental causes: thus, in ill-ventilated rooms, 
in crowded hospitals, where the atmosphere is impure from the number, 
disease, or filth of the inmates, malignant erysipelas, and hospital gan- 
grene are apt to occur. 

475. When an external part becomes gangrenous it loses all feeling 
and other vital properties ; its colour becomes livid, leaden, greenish, 
or almost black, the cuticle rises upon it in blisters, and begins to ex- 
hale an offensive odour. The rapidity of this change depends much 
on the moisture and warmth derived from the adjoining living parts; 
in dry gangrene, the dead portion becomes horny and black instead of 
putrefying. For the converse reason, in internal parts the progress of 
decomposition is more rapid. The putrid matter affects the living body 
as a local irritant, and as a general sedative poison or depressing agent ; 
and the symptoms vary much as one or the other of these two opera- 
tions predominates. 

In persons of robust constitution, active vascular system (§ 112, 120,) 
and good blood (§ 195,) a dead part arouses active inflammation and 
effusion of lymph in the surrounding living parts, and this may protect 
the system more or less completely from infection by the dead matter. 
In such cases, although gangrene be present, the predominant symp- 
toms may be those of inflammation and inflammatory fever. But living 
parts, with all their activity, cannot long withstand the pernicious in- 
fluence of dead and decomposing matter : so that if this matter be not 
soon thrown off in the form of a slough (§ 473.) or liquefied in the in- 
flammatory exudations poured out, the system becomes infected, and 
suffers from its poisoning and prostrating operation. This will happen 
more surely and early, where the dead part is in the interior of the 
body, of great extent, surrounded by vascular texture, and where 
its decomposition is promoted by the warmth and moisture. In sub- 
jects of weak constitution, feeble vascular system, and blood defective 
in plastic matter (§ 196,) the irritation of dead matter may fail to ex- 
cite a protective (adhesive or plastic) inflammation, and the putrid or 
typhoid symptoms then show themselves earlier, and prove more speedily 
fatal. These symptoms are, — increasing feebleness and frequency of 
the pulse, reduction of the fever, collapse and extreme pallidity of the 
countenance, cold sweats, brown, dry, or clammy foul tongue, low de- 
lirium, or restlessness and agitation of manner, hiccup, fetid diarrhoea, 
urine very offensive or suppressed, coma or syncope, and death. In 
external parts, or in parts which communicate with the surface, the 
putrid odour of the gangrenous structure becomes a distinguishing phy- 
sical sign; in gangrene of the lungs it is communicated to the expec- 
toration and breath; in other cases, the whole body exhales a fetid 
odour. 

The supervention of gangrene sometimes terminates the pain and 



GANGRENE — MIXED RESULTS. 



317 



other severe symptoms of the preceding inflammation, and thus induces 
a false calm ; but they are often replaced by distressing symptoms of 
nervous irritation, which subside only with the collapse of death. 1 

476. In concluding this account of the results or terminations of 
inflammation, I must repeat what was said at the beginning, (§ 445,) 
that they rarely occur quite separately one from another, and in many 
instances they are all exhibited in different portions of an inflamed 
organ o>r texture. Thus resolution is always attended with some amount 
of effusion : lymph often has the colour, opacity, and much of the mi- 
croscopic character of pus ; suppuration is almost always preceded, and 
generally accompanied, by the effusion of some lymph ; abscesses are 
often attended with gangrene and sloughing of parts: these combina- 
tions are further illustrated by the terms, purulent lymph, flaky pus, 
sloughing ulcer, gangrenous abscess, kc. y which pathologists are obliged 
to employ in describing the things they see. 

VARIETIES OF INFLAMMATION. 

The character of inflammation varies with the predominance or de- 
fect of one or other of its constituent elements or results, or in conse- 
quence of its combination with some of the other elements of disease 
that have been already considered: or again it may be greatly modi- 
fied by the nature of the exciting cause, as is exemplified in what are 
called specific inflammations. The following peculiarities of inflam- 
mation require to be briefly noticed: — sthenic and asthenic; acute, sub- 
acute, and chronic: congestive; phlegmonous; erysipelas; pellicular or 
diphtheritic; hemorrhagic; and scrofulous. Of the specific inflam- 
mations, the gouty and rheumatic, the syphilitic and the gonorrheal, 
will be merely alluded to. 

477. The varieties of inflammation termed sthenic and asthenic cor- 
respond with the analogous varieties of plethora (§ 279,) hemorrhage 
(§ 360,) and flux (§ 393,) and are referable to a difference in the strength 
and irritability of the heart and arteries, and in the quality and quan- 
tity of the blood which they propel (§ 110, 120, &c.) Thus sthenic 
inflammation is marked by a strong hard- pulse, high fever (§ 442,) 
very fibrinous blood (§ 208, 438,) a full and active development of the 
chief symptoms of inflammation (§ 429,) and a tendency to the effusion 
of the more plastic products (§ 450.) Patients affected with sthenic 
inflammation require and bear more antiphlogistic treatment than 
others ; and if used in time, such treatment is commonly very successful, 
for this form of disorder occurs in subjects of the most robust constitu- 
tion, in whom, therefore, the effects of disease are most readily shaken off*. 

Asthenic inflammation occurs in persons, the tone and real strength 
of whose vascular system is low (§ 116, 123,) and whose blood (gene- 
rally speaking) is poor (§ 207. J The pulse is not always affected; but 

1 For much instructive information on the subject of mortification, as well as on other 
matters connected with this chapter, see- Mr. Paget's admirable Lectures on Surgical 
Pathology. Although he differs from me in a few points, I am gratified in being able to 
refer to the works of this excellent observer for a confirmation of many of the statements 
and opinions which I have long since put forth. 



318 



INFLAMMATION — VARIETIES. 



when it is so, it is in frequency rather than in strength or firmness; 
the fever, if there be any, is of a slight remittent, or low character 
(§ 442, &c.) The products of the action are either scanty, or of a 
cacoplastic or aplastic character (§ 451 ;) or the effusion may be chiefly 
watery, the inflammation differing little from flux and dropsy. 

478. The terms acute, subacute and chronic, applied to inflamma- 
tion, properly relate to its duration ; but they are often used in the 
sense which I have given to sthenic and asthenic. Acute inflamma- 
tion may be, and commonly is, sthenic ; but it is by no means always 
so : its distinctive character is, that it tends to a speedy termination 
of some kind or other. It may end in resolution, effusion, suppuration, 
or gangrene, in a period varying from a few days to three weeks. 
An inflammation lasting above the latter period is termed subacute, 
and if protracted beyond six weeks is properly called chronic. Very 
commonly, inflammation is acute because it is severe or sthenic, its in- 
tensity leading to a speedy result: but asthenic inflammation is often 
also short in its duration ; whilst chronic inflammation sometimes pre- 
sents a good deal of the sthenic character (§ 477.) Acute inflamma- 
tion, when at all extensive, is attended with considerable fever and con- 
stitutional disorder. With subacute inflammation the fever is less, and 
may even be absent. In chronic inflammation there is rarely much 
fever, and when present, it is of a remittent or hectic kind (§ 444, 471.) 

The products of acute inflammation are commonly so copious as to be 
distinct in character, being either coagulable lymph, pus, or inflammatory 
mucus. In subacute inflammation the products are often of interme- 
diate nature, as instanced in purulent lymph, curdy matter, and tu- 
bercle in some of its forms. In this, as in asthenic inflammation, the 
more they are in quantity, the less likely they are to become well or- 
ganized. 

479. Chronic inflammation may originate in the acute or subacute 
forms, the vascular obstruction and excitement persisting in the part, 
even after some of the results (§ 445, formerly called terminations) of 
inflammatory action have been produced. Its general character is as- 
thenic ; but there may be considerable determination of blood and local 
excitement. Its effect in disturbing the functions, both of the part 
which is its seat, and of other parts, is much less prominent than is 
the case in acute inflammation ; but its duration causes a more serious 
and lasting alteration of structure. The matter effused by serous mem- 
branes in chronic inflammation is always either cacoplastic or aplastic; 
hence, dense and contractile adhesions, or patches of fibro-celluiar or 
semi-cartilaginous matter, cirrhosis, gray miliary tubercle, curdy and 
yellow tuberculous matter, are amongst its common products. Mucous 
membranes discharge muco-purulent, or curdy matter, and the more 
complex membranes of this class become thickened and sometimes even 
ulcerate. Sub-mucous textures become the seat of deposit, which, in 
becoming organized, often contracts, forming strictures in mucous pas- 
sages. These strictures, by obstructing the passages, sometimes lead 
to dilatations above. In glands and other complex textures, chronic 
inflammation causes consolidation and induration, and the hardened 
substance often afterwards contracts and effects the obliteration of con- 



CONGESTIVE — PHLEGMONOUS — ERYTHEMATTC. 



319 



nected texture, as in the changes in the lungs, liver, and kidney, in- 
aptly designated by the name cirrhosis. 1 Sometimes the indurated 
parts become softened, from the pressure on their vessels (§ 463,) as 
in softening of the brain, or they undergo a process of irregular sup- 
puration and ulceration, as in the excavation of the lungs after chronic 
inflammation. As was noticed regarding congestion (§ 311,) so it may 
be added of chronic inflammation, that the hypertrophy or excessive 
deposit of nutritive material is irregular, more in some textures than 
in others, generally abounding most in the interstitial cellular or fila- 
mentous tissu^, which then presses on the vessels and other textures, 
and so often causes their atrophy and partial obliteration. Chronic 
inflammation in the cartilages ends in caries and ossification: in the 
bones also it causes caries or exostosis, just as in the skin and other 
compound textures it leads to induration as well as ulceration. Jhe 
production of these apparently opposite results by the same process, 
inflammation, is not paradoxical, when the compound character of that 
process is borne in mind, and also the diversity that is due to the dif- 
ferent proportions of its elements and products. Chronic inflammation 
exhibits these opposite results the more strikingly, because its effects 
accumulate in consequence of its long duration ; the hypertrophy arising 
from one of its elements (determination of blood) increases in the im- 
mediate neighbourhood of atrophy and ulceration, the results of ano- 
ther of its elements (vascular obstruction.) 

480. Congestive inflammation is that in which the accumulation of 
the blood in the vessels of the affected part, and retardation of its move- 
ment, predominate over the determination of blood. Hence it is com- 
monly asthenic in its character (§ 477,) and generally originates from 
causes that produce congestion in the first instance (§ 403,) the reac- 
tion which converts this into inflammation being imperfect or partial. 
Its symptoms are less prominent than those of more active inflamma- 
tion, and partake more of the character of those of congestion. Thus 
there may be little pain, heat, fever, and other signs of irritation or 
increased action ; but the redness (where visible) is more marked and 
deeper than usual, and if the affected organ be very vascular, (as the 
liver, lungs, and kidneys,) the swelling may be considerable. Con- 
gestive inflammation is usually subacute or chronic, not tending to 
speedy results ; but a kind of flux or dropsy may occur early, as hap- 
pens from congestions (§ 375.) So, too, the solid effusion which fol- 
lows on it is generally cacoplastic, like that of congestion (§ 311 ;) 
hence the consolidations or indurations arising from it are often of a 
dense indolent kind, tending to contract, or to degenerate still farther 
into aplastic matter, (tubercle.) The inflammation of the lung super- 
vening on disease of the heart, on bronchitis, and on asphyxia, is ge- 

1 Mr. Gulliver describes the consolidation of chronic pneumonia as characterized by 
"dark exudation corpuscles," pale exudation corpuscles being the chief objects in red or 
acute hepatization. It appears, however, that these corpuscles are not dark from colour, 
but merely from opacity, as pus and tubercle are ; and they bear a further resemblance 
to this last product in their irregularity, and in shape, size, and composition, being of 
various forms, and consisting of molecules, generally without a nucleus, and often with- 
out envelope. — Notes to Dr. Boyd's "Vital Statistics," Edin. Med. and Sur. Jour., July, 
1843. 



320 



INFLAMMATION — VAEIETIES. 



nerally congestive ; and so is inflammation of the liver from all varie- 
ties of cause. I 

481. Phlegmonous inflammation is exemplified in the phlegmon, 
furuncle, or boil of the integuments. Its chief character consists in 
its being abruptly circumscribed by an effusion of solid lymph, -which 
brings the inflammation to a termination, either by suppuration, or by 
slow subsidence, as in the case of blind boils. A highly fibrinous con- 
dition of the blood (§ 195) contributes to render inflammation phlegmo- 
nous ; but this form of inflammation is commonly exhibited by cellular 
and parenchymatous textures. The type of phlegm onous^mflammati on 
is usually sthenic (§ 477 ;) and even where it advances to suppuration 
or sloughing, it defends the body against the noxious influence of the 
pus and dead matter. Hence the fever is inflammatory (§ 442,) and 
the local pain, irritation, and heat, are considerable. 

482. Erythematic or erysipelatous inflammation is contrasted with 
phlegmonous, in its tendency to spread, in consequence of its not being 
attended with the effusion of plastic lymph. In its severe forms, it is 
accompanied by much redness, pain or smarting, heat, and swelling; 
the effusion is chiefly serous, or sero-purulent, and often raises the cu- 
ticle in blisters. In its worst kinds it terminates in diffused suppura- 
tion, sloughing, or gangrene. The fever is also of a lower type (§ 443) 
than in phlegmonous inflammation ; being attended by great weakness, 
disorder of the secretions, foulness or dryness of the tongue, delirium, 
and confusion or dulness of the senses; and in the worst cases, the 
fever becomes typhoid, with stupor, muttering delirium, dry brown 
tongue, sordes on the teeth and lips, slight convulsive startings of the 
limbs, (subsultus tendinum,) fetid or suppressed excretions, and sinking. 

These adynamic or typhoid symptoms indicate the presence of some- 
thing more than a mere form of inflammation, and that something must 
be considered to be a poison. It is probable that this poison is some- 
times communicated as an infection (§ 93;) for persons living in the 
same room, or having had much communication with a patient suffer- 
ing from erysipelas, are more frequently attacked than others ; but it 
is also pretty certain that bad ventilation, and a crowded unclean state 
in surgical patients, are capable at any time of rendering common in- 
flammation erysipelatous ; this effect is also much promoted by unknown 
epidemic conditions of the atmosphere (§ 89.) The most probable hy- 
pothesis that can be formed regarding this "matter is, that under cer- 
tain circumstances the products of inflammation become poisonous; and 
capable of acting (as many animal poisons do) as local irritants and 
general sedatives or depriments ; that then they modify the character of 
the inflammation and depress the whole vital powers, (as we have found 
pus and gangrenous matter to do, § 471, 475;) and that these effects, 
and the general and local reaction set up against them (§ 17,) lead to 
the various degrees and forms which erysipelatous inflammation and 
its accompanying fever are found to present. The same morbid mat- 
ter, being then transferred by any of the three modes of infection 
(§ 94) to other persons may convert previously existing inflammation 
into erysipelas, or if strong enough, may develop it anew in the body. 
The fact that patients often sicken with fever, (rigors, vomiting, head- 



ASTHENIC — DIPHTHERITIC. 



321 



ache, quick pulse, delirium, &c.,) before the erysipelatous inflammation 
appears, is a sufficient proof that the poison acts on the constitution 
as well as on a part ; and the fact that weakly persons, and those with 
previous structural disease, (especially of the kidneys,) suffer most from 
the effects of erysipelas, shows the essentially depressing operation of 
the poison. In several cases of the worst forms of erysipelas, I have 
found pus globules in considerable numbers in the blood of parts re- 
mote from the affected textures; this corresponds with the observations 
of Mr. Gulliver (§ 462.) This seems to suggest that pus may be the 
poisonous matter that sets up the mischief ; but although it is highly 
probable that these pus globules do possess the septic tendency formerly 
noticed as belonging to foul kinds of matter (§ 462, 3,) yet it is likely 
that the poison of erysipelas wears a more subtle form, spreading itself 
in solution or even in vapour, as illustrated by the pernicious proper- 
ties of the liquor puris, and its fetid odour (§ 470, 472.) 

Some asthenic inflammations of mucous and serous membranes and 
of internal organs exhibit many of the constitutional effects of the 
worst forms of erysipelas ; they sometimes prevail when this disorder 
is epidemic, and may be traced to the same infection. This is espe- 
cially the case with puerperal metritis and peritonitis, erysipelatous ton- 
sillitis and laryngitis, and suppurative phlebitis. 

483. Pellicular or diphtheritic inflammation of mucous membranes 
has some affinity to the erysipelatous, being diffused and spreading, 
generally asthenic, and accompanied with a low kind of fever. It is 
attended with more soreness than pain, little swelling, and a deep red- 
ness, which is early obscured by the characteristic film of grayish or 
dirty white albuminous matter, which is exuded on the inflamed sur- 
face. Patches of this kind often occur on the tonsils in sore throat, and 
have been commonly mistaken for sloughs. In certain epidemics, often 
connected with scarlatina, a diphtheritic inflammation affects the whole 
throat, and sometimes extends to the trachea and air tubes, the mouth, the 
gullet, and to more or less of the alimentary canal. The films of lymph 
thus effused are often fetid, apparently from incipient decomposition, 
which is promoted by their exposure to air and moisture in the throat 
and air passages. As in the case of diffused suppuration and gan- 
grene, this tendency of the result of inflammation to putrefy is at once 
a sign of the low condition of the vital powers, and a cause of their 
further depression. 

The exudation of lymph instead of the mucus or purulent mucus 
more commonly effused, I am disposed to refer to the inflammation af- 
fecting the submucous cellular tissue, and to its being at the same time 
diffused like erysipelatous inflammation. Deep-seated inflammation of 
a more sthenic character is circumscribed by the effusion causing a 
thickening of the membrane, as in laryngitis; but the matter effused 
by diphtheritis, although fibrinous, is thin enough to transude through 
the mucous membrane on whose surface it concretes. The thinness of 
the mucous membrane of the air passages in children facilitates such 
transudation in their deep-seated inflammations: hence, at an early 
age, all such inflammations may cause an effusion of fibrinous matter, 
as we find exemplified in croup. So, too, the extreme tenuity of the 
21 



322 



INFLAMMATION — VARIETIES. 



mucous lining of the smaller divisions of the air-tubes makes the exu- 
dation of fibrinous matter a common result in pneumonia and some 
kinds of capillary bronchitis. This is exemplified in the ramiform 
moulds of the bronchial tubes sometimes expectorated. Similar skin- 
like exudations are occasionally passed from the intestines after the 
irritation of calomel or other strong purgatives, and in some cases 
without any such irritation. I have had several patients under my 
care who from time to time pass from the bowels a quantity of shreds 
like white kid leather, without any symptoms of active inflammation: 
congestion seems to be a chief cause in these cases (§ 308.) 

Various asthenic inflammations of the mouth and throat seem to be 
capable of causing a fibrinous exudation, resembling that which is pro- 
duced by mercurial action, and that which is seen in the aphthous 
mouth and throat of adults, common towards the fatal termination of 
various chronic diseases. Recent microscopic observations have proved 
that in some of such cases at least, the film consists chiefly of a coii- 
fervoid vegetable. I ascertained this to be the case with a remarka- 
bly white curdy coating on the fauces and gums of an aged female, 
who was under my care in the hospital in July 1847; the matter was 
almost totally composed of the jointed tubes, and brilliant sporules 
and granules of a parasitic growth. The aphthee of children are some- 
what different, being vesicular elevations of the epithelium, with or 
without an albuminous film underneath. 

484. Hemorrhagic inflammation is entitled to be considered as a 
distinct variety. In most inflammations, there are slight extravasa- 
tions of blood; but sometimes there is so much colouring matter in the 
inflamed texture and in the products effused, that it may be difficult 
at first to say from the appearance whether the disease is a hemor- 
rhage or an inflammation. These inflammations I have found to be 
asthenic; often the subjects were scorbutic, or affected with purpura; 
and, as I have stated with regard to the latter disease (§ 358,) there 
has been distinct evidence of imperfect action of the liver and kidneys. 
Thus I have several times met with hemorrhagic pleurisy and pericar- 
ditis in conjunction with cirrhosis of the liver, and Bright's disease of 
the kidney. An altered condition of the colouring matter (§ 186) of 
the blood is perhaps more concerned in causing this result than a defi- 
ciency of the fibrin, to which it is commonly ascribed: in fact, this is 
found to be more or less in excess as in other inflammations, but very 
probably it may be defective in its usual contractile property (§ 203.) 

485. Scrofulous inflammation is decidedly asthenic, and exhibits 
many deviations from the common form of inflammation. It is well 
exemplified in the lymphatic glands, one of its most common seats, and 
within the reach of direct observation. These glands, in common in- 
flammation, become very painful and hot, as well as swollen, and the 
inflammation tends soon either to resolution or to suppuration. In scro- 
fulous inflammation, on the other hand, the glands swell to a great size ; 
and often the deep redness extends to the surface, but with little pain 
or heat ; and the swelling remains for a very long period without either 
resolution or suppuration, and is little influenced by antiphlogistic 
remedies. Sometimes the swelling looks very red, and seems to sup- 



VARIETIES — HEMORRHAGIC — SCROFULOUS. 



323 



purate, so that distinct fluctuation is perceived, but afterwards the skin 
becomes wrinkled, and the swelling subsides. When it does burst, or 
is opened, the pus is serous and curdy, or mixed with matter of a soft 
cheesy consistence, (soft tuberculous matter;) and a deep ulcer with a 
narrow orifice (fistula) is left, which is indisposed to heal. The micro- 
scopic characters of scrofulous matter are a paucity, and irregular 
form, of the pus globules, and a great predominance of granular matter, 
loose or coherent in clots, and the presence of oil globules in consider- 
able numbers. These characters at once explain both the aplastic and 
the indolent properties of the matter ; they show why it is destitute of 
the organizability of fibrin, and of the cell developing and osmotic 
attributes of pus (§ 461.) In proportion as it gets older, as in cold 
abscesses, the pus globules become collapsed, and the liquid partly ab- 
sorbed, the matter acquires a cheesy or putty-like consistence, and in 
time undergoes a farther change into fatty matter and phosphate of 
lime. The kind of inflammation from which this has originated occurs 
in persons who possess what is called the scrofulous diathesis or con- 
stitution. 

The scrofulous diathesis is merely a term employed to designate a 
state of the body in which scrofulous inflammation and malnutrition 
are apt to occur. It has been generally stated that this diathesis has 
certain outward marks, by which its existence may be recognised inde- 
pendently of the actual occurrence of disease. Thus a relaxed state 
of the muscles, a soft transparent skin, a fair or pale complexion, with 
partial patches of a peculiar pink or purplish redness ; a pearly white- 
ness of the eye and teeth; a tumid- upper lip ; fair or reddish hair; large 
and weak joints, precocity of intellect, and some other analogous signs, 
have been described as characterizing the scrofulous diathesis. But 
such appearances may be presented without any manifestation of scro- 
fulous disease ; and still more frequently, scrofulous disease is induced 
in persons quite destitute of these characteristics. 

More constant concomitants of the scrofulous disposition (although 
they sometimes occur without scrofula) are, various signs of weak cir- 
culation and imperfect nutrition, such as cold extremities ; weak, but 
easily accelerated pulse ; small development of muscles ; uncertain diges- 
tion and irregular excretion ; and slow or defective healing of wounds. 
The circumstances which most favour the production of scrofulous dia- 
thesis are also influences of a weakening kind, especially when these 
are long continued, such as poor or insufficient nourishment, especially 
in childhood or youth ; cold and damp situations, or defective clothing ; 
long confinement in close, ill- ventilated habitations; long-continued ill- 
ness, especially from eruptive or typhoid fevers ; and prolonged and 
aggravated disorders of the digestive organs. Scrofula is also, in a 
marked degree, an hereditary affection (§ 36 ;) and mere feebleness of 
constitution in parents, whether original or from disease, or from in- 
dulgence in excesses, or from advanced age, often develops a disposi- 
tion to scrofula in children. 

In persons of the diathesis now noticed, inflammation frequently runs 
a course, and leads to results which are different from those that ensue 
in a healthy subject. Commonly the inflammation is more asthenic 



324 



INFLAMMATION — VARIETIES, 



(§ 477;) often it is more subacute or chronic (§ 479) than usual: but 
in all cases, its solid products are not euplastic (§ 450,) as in healthy 
persons ; but either cacoplastic (§ 452) or aplastic (§ 453,) according 
to the prevalence of the scrofulous constitution, the texture affected, 
and the quantity of the inflammatory product thrown out. Where the 
scrofulous diathesis is most developed — where the texture inflamed is 
an internal one, and so placed as not to be able to discharge freely 
externally — and where the product of inflammation is most copious, — 
there the deposit will be most aplastic, consisting of scrofulous pus or 
yellow tubercle, devoid of regular structure, and wholly insusceptible 
of organization; and being unfit for absorption, it then operates as a 
foreign body, irritating, obstructing, and compressing the adjoining 
parts, in various ways detrimental to their functions and structure. 
Thus arise tuberculous or scrofulous deposits and abscesses in lympha- 
tic glands, in bones, cartilages, and in the connected cellular textures, 
tuberculous infiltrations in the lungs, and deposits in serous cavities. 
Where the scrofulous diathesis is less pronounced, and the inflamma- 
tory effusion less copious and more gradual, the result may be a caco- 
plastic product, susceptible of only a low organization ; as gray, miliary, 
and tough yellow tubercle ; cirrhosis, atheroma of arteries, fibro-carti- 
lage, and other degraded living solids. These have been already noticed 
(§ 453, 454,) and will again come under consideration as products of 
altered nutrition. The aplastic tendency of inflammation in scrofu- 
lous subjects is sometimes manifest in other forms in different textures. 
Synovial membranes of joints are softened into a brownish pulp, 
(Brodie;) articular cartilages and the cornea ulcerate, from absorption 
predominating over nutrition (§ 466 ;) the integuments of the face and 
other parts inflame in small cutaneous tumours or tubercles, which 
ulcerate, and for want of plastic material, the ulcers become phagede- 
nic and spreading, and destroy the nose or adjacent parts, as in lupus. 

It seems, then, that the most marked peculiarity of scrofulous in- 
flammation is, that it degrades or arrests nutrition, by supplying a 
material that is little or not at all susceptible of organization. This 
leads us to inquire what is the condition of the blood in scrofula ; the 
answer is found in the fact ascertained by Andral and Gavarret, and 
before mentioned (§ 454,) that there is an excess of fibrin (§ 195,) and 
a deficiency of red corpuscles (§ 185.) The fibrin is, however, de- 
fective in that finely fibrillated structure that is indicative of plasticity. 

486. Gouty and rheumatic inflammations have already been noticed 
when speaking of their specific cause, a morbid matter in the blood or 
in the textures (§ 251, 254 ;) and some of the peculiar characters of 
this kind of inflammation were then adverted to (§ 385.) It is highly 
probable that the peculiar features of many other inflammatory affec- 
tions, especially of the skin, such as urticaria, eczema, psoriasis, and 
erythema, may be referred to a similar cause, a particular matter con- 
tained in the blood, and irritating the parts through which it circu- 
lates (§ 402.) 

487. The poisons of gonorrhoea and syphilis excite inflammations 
still more peculiar in their phenomena and course. Gonorrhoea! in- 
flammation chiefly affects the genito-urinary passages and the conjunc- 



* 



TREATMENT OF INFLAMMATION. 



325 



tiva. It is generally acute, and results in the secretion of an opaque 
sulphur-coloured pus, which is capable of communicating the disease. 
Sometimes it affects the testicle also with acute inflammation, and the 
joints with a more chronic kind, constituting then gonorrhoea! rheuma- 
tism. 

Syphilitic inflammation exhibits great variety in the sites it attacks 
and in the effects it produces. Locally, the syphilitic poison excites a 
papula, or small tubercle on any delicate membrane it touches, which, 
ulcerating, then forms a chancre. As the matter is absorbed from this, 
it causes inflammation with great pain and swelling of the neighbouring 
lymphatic glands (bubo,) which may pass on to suppuration. These 
are primary inflammations, and of an acute character. When thorough- 
ly in the system, it may excite secondary inflammations ; sore throat, 
generally of an asthenic type, and tending to ulcerate; and a great 
variety of affections of the skin, which differ greatly in their character, 
according to the vigour, &c, of the subject. These often leave a pe- 
culiar livid or copper coloured stain in the under layer of the epidermis, 
which obviously arises from an extravasation of some colouring matter 
from the blood, and probably implies a change in it. The periosteum 
and bones are also often attacked with syphilitic inflammation; and 
painful nodes, exostoses, suppuration, and caries, result. The iris is 
sometimes affected with acute inflammation, leading to an effusion of 
lymph, which may endanger the sight if not arrested in time. 

TREATMENT OF INFLAMMATION. 

488. We have found inflammation to be an essentially complicated 
process, consisting of several constant elements, to which are frequently 
added other accidental ones, which then farther increase the complexity 
of the disease. A proper knowledge of these several elements, and of 
the means which best remove or counteract them, separately and in 
combination, forms the best guide to the rational treatment of inflam- 
mation, and supplies a safe clue to the comprehension of the confused 
and paradoxical assemblage of agents which experience has proved to 
be antiphlogistic remedies. As we have not time to discuss in full de- 
tail all the constituent elements and results of inflammation in relation 
to treatment, we propose simply to enumerate them, with a reference 
to the text, that affords a more full explanation, and then to express in 
a tabular view the remedies that may be best employed for each. This 
table therefore comprises an enumeration of the different agents used 
in what is termed the antiphlogistic treatment. 



326 



INFLAMMATION — CONSTITUENTS. 



From operation 
of 

exciting cause. 



Local elements 
cf inflammation, 
(essential.) 



Constitutional 

effects of 
inflammation, 
(not essential.) 



489. Constituents of Inflammation, 

Congestion (g 403, 407,) 
or 

Nervous and vascular irritation (\ 402, 408.) 
Determination of blood towards the affected part ($ 409, 419.) 
Obstruction of the vessels most affected {\ 410, 419;) by atonic en- 
largement of the capillaries (£ 414;) by impaction of blood corpuscles 
within them (§ 415.) 
Distention of arteries and capillaries behind the obstruction ($ 420,) 

causing effusion [\ 423) of serum, lymph, pus, &c. (§ 427.) 
Emptiness of veins beyond the obstruction (| 427,) inducing increased 

absorption (§ 467,) and thence softening, &c. 
Impeded or arrested circulation at the obstruction 418,) causing a 
reduction or abolition of vital properties (§ 273,) hence the death 
of the structure and its removal by ulceration [\ 466,) and suppu- 
ration ($ 427.) or by the decomposition of gangrene ($ 473.) 
Increased circulation of blood around the obstruction (| 410,) causing 
exaltation of vital properties there (g 421, 333;) hence spasm (g 113,) 
pain {\ 135,) sympathetic irritations (§ 149,) increased secretion 
(gl59,)&c. 

Extension of the excitement to the heart and arteries (g 440,) causing 
inflammatory fever. 

Change of composition in the blood, by increase of fibrin furnished by 
the inflamed part (§ 438,) and in consequence of diminution of ex- 
cretion attending the inflammatory fever (g 441.) 

Exhaustion ensuing after the excessive excitement (g 116,) or in con- 
sequence of effusion (g 459, 470.) 

Depression, sometimes with local irritation, caused by the presence of 
pus or gangrenous matter in the blood (g 470, 475,) and retention 
of excrementitious matter 443.) 



490. TABULAR YIEAV OF THE CONSTITUENT ELEMENTS OF INFLAMMATORY 



DISEASE, "WITH THE 

CONSTITUENTS OF INFLAMMATION. 

1. Congestion , 

2. Irritation of nerves . . . . , 

3. of vessels . . . . 

4. Determination to the part . . , 

5. Obstruction in the part: 

by atonic enlargement . . 

6. by adhesion of corpuscles . , 

7. Distention of vessels .... 

8. Effusions , 



9. Increased absorption 



10. Impeded circulation in the part 

11. Increased circulation around . 



REMEDIES ADAPTED TO EACH. 

ANTIPHLOGISTIC REMEDIES. 

f Astringents ; stimulants ; evacuants ; *] 

\ (§ 315, et seq.) j 

Narcotics; counter-irritants (g 137, 155.) - 

f Sedatives ; derivatives; evacuants; 

t (I '342, et seq.) 

J Cold and other sedatives ; derivatives ; ] 
\ evacuants 



Same remedies as for 1. Congestion . 

Remediesuncertain: attenuants ? ($ 217;) 

sedatives? (J 416) 

f Counter-pressure ; blood-letting; deri- 

\ vation (§319) 

j Evacuants; derivatives; operations; 

X sorbefacients? 

( No direct remedies known ; stimulants ; 
< diminishing atmospheric pressure on 

( the part ? . 

J Moist heat and other stimulant applica- 

X tions 

f Remedies for 4. Determination, (see 
X above) J 



C 53 



ANTIPHLOGISTIC REMEDIES. 



327 



CONSTITUENTS OF INFLAMMATION. ANTIPHLOGISTIC REMEDIES. 

12. Excitement of the heart. . . . /General blood-letting and other eva-] i «f 

( cuants; sedatives ($ llo) . . . . © . 

{General blood-letting and other eva- | § 
cuants; relaxants, (antimony, &c. I | fi c2 
I 122;) salines -jib 

14. Change of the blood: \ 

{Blood-letting and other evacuants; 
(| 214;) mercury; salines; low diet, 
cod-liver oil? 

15. by diminution of the excreO . , ^ t-o J 

t j ong vEliminants; alteratives (g 1 / 2, et seq.) . 

16. Exhaustion Stimulants and tonics ($ 119, 124) . 

-.- -p. n • • ^^ j f Stimulants; antiseptics; evacuants; 

1/. Depression from poison in blood . ^ ($ 2G0) 

f Eliminants ; attenuants ; alteratives ; 
18. Effused products of inflammation . -j sorbefacients? stimulants; pressure, 

I and friction 



o 

11 

n .3 

o 



3^ 



491. Mj limits will not allow me to do more than offer brief com- 
ments on these principles of treatment, and to exemplify them by a 
few of the results of my own experience ; and it is an important corro- 
boration of the truth of these principles that they expressly indicate 
the advantages that are attained from the use of the various remedies 
which have been found effectual in the treatment of inflammation, they 
suggest the peculiar uses of them respectively, and they open to us a 
path of inquiry in pursuit of others which are yet wanting. 

Remedies for incipient Inflammation. 
1. Congestion. The efficacy of topical astringents and stimulants 
in removing the congestion which precedes inflammation, is illustrated 
in the effect of a strong solution of nitrate of silver or sulphate of zinc 
in curing conjunctival ophthalmia, and of the same agents, of powdered 
alum (Yelpeau,) and of capsicum gargles, in curing an incipient sore 
throat. But as it is with congestion (§ 317,) so also is it still more 
strikingly with the congestive stage of inflammation. If it be extensive, 
long established, or already complicated with determination of blood, 
astringent applications can never restore the lost tone, nor clear the 
obstruction of the vessels ; and therefore can only operate as irritants, 
and aggravate the inflammation under these circumstances; it is then 
that evacuants, derivatives, and even blood-letting, are more appro- 
priate. The utility of these measures has been alluded to under the 
head of congestion (§ 318;) but their employment is commonly even 
more necessary in the congestive stage of inflammation, inasmuch as 
this tends to farther and worse results. A strong purgative and dia- 
phoretic, if given early enough, may suffice to remove an incipient in- 
flammation ; but if this inflammation be extensive, and more especially 
if the subject be plethoric, the proper remedy, even at this stage, is 
blood-letting, local or general, according to the situation and extent of 
the mischief. 

492. — 2 and 3. Irritation of nerves and vessels. The irritation of 
the nerves, which we have found to constitute a part of the commence- 
ment of some inflammations (§ 403,) is so closely followed by irritation 
of the vessels, that the same remedies are adapted to be serviceable 
for both. The efficacy of a large dose of opium in incipient inflamma- 



328 INFLAMMATION — TREATMENT. 

tion exemplifies the power of narcotics to subdue the nervous irritation, 
and such remedies are the more indicated when pain, spasms, and other 
signs of excited nervous function (§ 151,) predominate. On the other 
hand, when heat and redness prevail, the disturbance is more in the 
vessels, and the appropriate remedies then are sedatives, such as the 
application of cold and saturnine lotions to the part, and the employ- 
ment of various evacuants and derivatives, which draw the blood away 
from the distended vessels. Counter-irritants or revulsives of the most 
speedy operation, such as heat, dry and moist, mustard poultices, and 
other stimulating applications, made near the affected part, seem to 
act both on the nerves and vessels, and so are powerful means for sub- 
duing the irritation which leads to inflammation. The effect of these 
applications on nervous irritation is in proportion to the sensation which 
they produce ; when pain or other sign of nervous excitement predo- 
minates, a heat almost scalding or burning, or stimulating agents which 
cause severe smarting prove most effectual. On the other hand, when 
the vessels are most excited, as evinced by heat and redness, (if visible,) 
counter-irritants or revulsives which act extensively rather than in- 
tensely, are of more avail; as for instance, a general or partial hot 
bath, or a large poultice, or fomentation, made more stimulant by va- 
rious additions. 1 Purgatives and other evacuants are still indicated 
here, on the same principle. Emollient and demulcent agents, when 
they can be directly applied, often soothe an inflamed surface, at the 
same time by promoting the natural secretion, by removing irritating 
matter which may have helped to cause the inflammation, and by re- 
ducing the acrimony of the morbid discharge (§ 455.) 

Remedies for established local Inflammation. 
493. — 4. Determination to the part. This, with the next condition 
specified, obstruction in the part, is only a farther result of irritation of 
the vessels ; but it is convenient to speak of it here as a constituent of 
established inflammation. It is to be opposed by the same remedies as 
those just mentioned as appropriate for vascular irritation, and those 
formerly noticed as suitable for simple determination of blood (§ 342, 
et seq.;) but in consequence of belonging to a disease which is more 
enduring and serious, the determination attending inflammation requires 
a bolder employment of the measures. Of sedatives none is so effec- 
tual under these circumstances as the application of cold; it promotes 
the contraction of arteries (§ 120) more than any other agent. It is 
thus that ice and cold lotions prove salutary in reducing active inflam- 
mation when they can be properly applied, as they can if the affection 
is external: in some internal inflammations the cold may be still made 
to reach the organ affected, as when a bladder of ice is applied to the 
head in meningitis, and when small pieces of ice are slowly svfallowed 

1 A great improvement in the facilities for fomenting parts with hot water, with or 
without stimulating additions, is supplied by the various water-proof fabrics, such as 
India rubber cloth, oiled silk, or gutta percha sheet, which being applied as a cover, pre- 
vent the rapid escape of the heat and moisture. I have for many years adopted these 
auxiliaries with great advantage, especially where a prolonged effect is desired. The 
India rubber epithems, called piline and spongio-piline, introduced into this country by 
Mr. Markwick, answer the purpose very well. 



REMEDIES — FOR INCIPIENT — FOR LOCAL INFLAMMATION. 329 



in gastritis. Cold will do harm instead of good in inflammation, either 
if it does not reach the enlarged arteries through which the increased 
flow takes place (§ 326,) or if it is not sustained long enough to pre- 
vent the effects of reaction (§ 79,) by which the arteries again become 
enlarged so that the determination is renewed. For these reasons, 
external cold applications are injurious in most internal inflammations, 
and if not steadily regulated, they may prove so in other cases like- 
wise. 

Warmth and other clerivant influences addressed to parts more or 
less remote from the vessels which are the channels of determination 
are very serviceable aids in the treatment of this element: partial or 
general warm baths, hot poultices, &c, operate in this way. Diapho- 
retics, such as antimonials, which equalize the circulation without sti- 
mulating, are also beneficial, because they relax the cutaneous vessels 
generally, and thus derive to the whole surface. So too we noticed 
(§ 345) that purgatives and diuretics operate as derivatives as well as 
evacuants ; and that blood-letting is the most effectual of all (§ 346.) 
Change of posture, by elevating the part inflamed, may also be men- 
tioned among the means which counteract determination of blood. 

These different measures, which may suffice in simple determination, 
may nevertheless prove insufficient for that attending inflammation, 
chiefly because their influences cannot easily be sustained for a con- 
siderable length of time. Various agents are therefore employed to 
produce a more enduring derivation or revulsion, as well by acting as 
counter-irritants, as by exciting artificial inflammations in other struc- 
tures and parts. To this class belong blisters, mustard poultices, ap- 
plications of tartar emetic, croton oils, strong ammonia, mineral acids, 
some of the essential oils, heat above 120° Fahrenheit, &c. : the amount 
of inflammation which is excited by their employment varies according 
to the manner and duration of their application. As these fulfil se- 
veral distinct indications in the treatment of inflammations, they will 
again come under our notice. 

494. — 5 and 6. Obstruction in the part by atonic enlargement of the 
capillaries, and by adhesion of the white corpuscles and accumulated 
impaction of the red. These are classed together, because they joint- 
ly combine to keep up the partial obstruction which is characteristic of 
inflammation. The atonic enlargement of the capillaries may be said 
to be included in the congestion before noticed; but it stands here as 
a part of established inflammation, which is different from mere con- 
gestion (§ 287.) The remedies to be addressed to it are, however, the 
same in both cases ; but here they generally occupy a subordinate place, 
unless they fulfil other indications. There are, however, a few cases 
in which treatment for congestion, even by stimulants, proves effectual 
in curing inflammation. Catarrhal inflammations of mucous mem- 
branes are sometimes removed by a highly stimulant treatment consist- 
ing of the administration of wine, spirits, or ammonia. It is proba- 
ble that then the accelerated circulation excites the dilated capillaries 
to contract and that the obstruction is thus swept away. This treat- 
ment when effectual generally causes sweating and a copious deposit in 
the urine ; but these seem to be as much effects as causes of the im- 



330 



INFLAMMATION — TREATMENT. 



provement, for sweating by other means is not so serviceable. This 
mode of treatment, however, is hazardous, for it acts by increasing the 
flow of blood, and if this fail to remove the obstruction, it will surely 
aggravate the inflammation. 

But the most constant and important part of the obstruction of in- 
flammation is due to the unusual impaction and stagnation of red and 
white corpuscles within the inflamed vessels ; and as it is this especial- 
ly that establishes inflammation, and is the cause of its most serious 
results, it would be very desirable to find some remedial influence ca- 
pable of counteracting it. Unfortunately, however, we are not ac- 
quainted with any direct means by which we can check the aggre- 
gation and cohesion of the pale and red corpuscles, or dissolve their 
union. As these little bodies are in osmotic relation to the blood liquor, 
the desired remedies must be sought among the medicines which affect 
the blood; and it might be surmised that the neutral and alkaline salts 
possess this virtue. They certainly are able to dissolve fibrin, and be- 
come neutralized by it — Dennis has shown that the fibrin of venous 
blood is dissolved by digestion with a solution of nitre, and reduced to 
the condition of nonplastic albumen — Mr. Gulliver finds that the neu- 
tral salts do tend to keep the blood corpuscles from becoming adherent. 
The efficacy of carbonate of potash as an antiphlogistic remedy has 
been much vaunted by Sarconi and other Italian writers; but this does 
not appear to have been confirmed by universal experience. Some 
experiments of Mr. Blake's (§ 214) seemed to indicate that salts of 
potass, injected into the veins, promote the coagulation and stagnation 
of the blood instead of preventing them. If the chemical view of the 
augmented adhesiveness, already propounded (§ 417,) be correct, it may 
be inferred that such measures would be most likely to be effectual in 
obviating it, as would tend to interrupt the hyper-oxidation of the 
plasma ; and as this must depend very much on the flow of arterial blood 
which brings the oxygen to the part, we are led to a new reason for the 
advantageous operation of depletion, derivation, sedatives, and other 
influences that reduce the force of the local and general circulation, 
as well as the richness of the blood which supplies the inflammatory 
material. Yv 7 hether any direct deoxidizing agent can be made to con- 
duce to the same end is a question worthy of careful investigation ; 
most medicines calculated to produce the result are objectionable on 
account of their stimulant or heating influence, as for example, alcohol 
and oils, and in a minor degree, sugar and starch. The deoxidizing 
agent should possess no such property, either before or after its own 
oxidation. May not the antiphlogistic operation of antimony and mer- 
cury owe something to their fulfilling this condition? Their virtue 
certainly is chiefly confined to their protoxides and proto-salts. Ana- 
logous preparations of other oxidizable metals, which have no sti- 
mulant or injurious action, and sulphurets of metals and alkalies, have 
formerly enjoyed some repute as remedies in inflammation, and possi- 
bly may deserve yet further trials. I have myself found that the most 
efficacious remedy for certain cutaneous inflammations, such as acne 
simplex and rosacea when in an excited state, is a weak solution of 
sulphuret of potash used as an outward application; and sulphuretted 



REMEDIES FOR LOCAL INFLAMMATION. 



331 



waters are well known to be useful soothing agents in irritable condi- 
tions of the alimentary canal — possibly owing to some operation of an 
analogous kind. There is, however, one important fact that is worth 
bearing in mind, while the influence of sulphur compounds is under 
consideration. It is, that albumen contains more sulphur in its com- 
position than fibrin. There is no doubt that fibrin can be changed 
into albumen in the living system as well as the converse, and possibly 
the mere presence of a superfluity of sulphur, under certain circum- 
stances, may determine the change. As the presence of a superabun- 
dance of white corpuscles, and an augmentation of the fibrinous con- 
stituents of the blood are constantly found to occur simultaneously, 
it seems highly reasonable to seek agents capable of influencing the 
condition of the white corpuscles, amongst such as are, known to pos- 
sess chemical power over fibrin. 

495. — T. Distention of vessels. This condition, which has been al- 
ready explained as the result of determination of blood into congested 
and obstructed vessels, is another highly characteristic constituent of 
inflammation. Distention sometimes occurs in congestion (§ 306;) but 
then it chiefly affects the veins ; here it is in the small arteries, and in 
all those parts of the capillaries that are on the arterial side of the ob- 
struction. This in some degree accounts for the greater degree to 
which it attains, and the larger amount of effusion and other changes 
that result from it. But the peculiarity of inflammatory distention and 
of its consequent effusions cannot be well understood without keeping 
in view that concentration or exaggeration of influence exerted by the 
red particles on the liquor sanguinis, when, on their accumulated and 
impacted masses, a strong current of arterial blood is continually im- 
pelled (§ 416.) This view, too, suggests that the most effectual means 
of relieving the distention, must be the speedily lessening either the 
determination of blood or the obstruction. The measures for reducing 
the determination need to be of the strongest kind, such as blood-letting 
and free derivation or evacuation ; for the arteries which are its seat 
are closed at their capillary ends, and must, therefore, be drawn upon 
from behind, and by influences which reduce the pressure in the ar- 
teries generally. When there is considerable determination of blood, 
the distention which it causes will not be relieved without drawing 
blood either from the enlarged vessels themselves, or from other parts, 
in sufficient quantity to reduce the heart's action and the general ar- 
terial pressure. 

There are other less powerful agents that afford some relief to the 
distention of vessels in inflammation. External pressure, carefully 
equalized, will sometimes do it, as instanced in the effect of well applied 
bandages and strapping on wounds. Fluid pressure, as proposed by 
Dr. Arnott, by means of quicksilver, or of the slack air-cushion ap- 
plied under a bandage, is capable of being made still more useful in 
various external inflammations, because its own quality ensures its pro- 
per application. It is very probable that a part of the efficacy of poul- 
tices depends on the soft and uniform pressure which they produce on 
the inflamed vessels. But poultices, fomentations, and other analogous 
applications of heat and moisture, certainly relieve distention also by 



3 32 INFLAMMATION — TREATMENT. 

relaxing the solid fibres, and by promoting the exudation of the watery 
parts of the blood. 

496. — 8. The effusions from the vessels, although attended with aug- 
mented vital actions and cell-formation, are partly caused by continued 
impulsive distention. They may therefore be prevented or lessened 
by means which reduce this distention. In severe cases of inflamma- 
tion, eifasion is the natural mode in which vessels are relieved -of their 
load, and should not be opposed; and we have just pointed out that 
poultices and fomentations give relief by promoting this result. If the 
effusion is outwards, as when furnished by a mucous membrane, it may 
not be necessary to check it, except so far as it is interfering with the 
functions of the part. Alkaline medicines often give relief by atte- 
nuating a thick secretion and so leading to easier effusion ; acids and 
astringents are the remedies that check it when it is too profuse, but 
blisters and various general evacuants should be employed at the same 
time, otherwise the inflammation may be increased; this corresponds 
with the principles laid down for the treatment of sthenic fluxes (§ 393.) 
When the effusion is into cellular texture, the parenchyma of organs, 
or a serous cavity, it may seriously interfere with the functions of the 
part; and it is therefore then important to prevent, restrain, or remove 
it. Thus, very slight effusion in the submucous cellular texture of 
the glottis, or into the serous cavities of the brain, may prove fatal ; 
and in the lungs or pleura, it becomes injurious in proportion to its ex- 
tent. It is doubtful whether we possess any other means of restraining 
effusion, beyond the employment of the ordinary remedies for determi- 
nation and vascular distention. It is pretty certain that some anti- 
phlogistic medicines, especially mercury and antimony, do diminish the 
effusions of inflammation, and promote their absorption ; but it is not 
clear, that they do so in any more direct way than by reducing the 
local and general excitement, or by their evacuant effect. The ex- 
pressions, "sorbefacient" and "exciting the absorbents," hypotheti- 
cally ascribe to remedies the power of increasing absorption ; but 
nothing in physiology points to any direct mode by which absorption 
can be artificially increased. A free action of the excreting organs 
promotes absorption indirectly, by reducing the distention of the vas- 
cular system. Absorption is also promoted by whatever renders the 
circulation free, without producing excitement or distention ; 1 the return 
of the vessels to a healthy state is generally attended with more or less 
absorption of effusions that have been thrown out. It is probable that 
blisters and other counter-irritant applications made near an inflamed 
part induce absorption not merely as evacuants or derivants, but also 
by causing a rapid flow of blood through the adjoining vessels, which 

1 In my Gulstonian Lectures (Med. Gaz., July, 1841,) I adverted to the effect of rapid 
movement of blood in promoting absorption. Dr. G. Robinson has since illustrated 
this by some experiments (Med. Gaz., May, 1843.) Another influence which probably 
contributes to the same result is the different density of the fluid within and without the 
vessels: that within is more dense and saline, and by the law of osmosis, tends to attract 
to itself the thinner fluid from without. This explains the greater readiness with which 
thinner effusions are absolved. Would it be possible to increase absorption by rendering 
the blood more saline than usual? The thirst experienced after taking salt food seems 
to be referable to this same cause ; and the beneficial influence of salines in inflamma- 
tory diseases may be partly due to this mode of operation. 



REMEDIES FOR LOCAL INFLAMMATION. 



333 



facilitates the operation of osmosis, and the removal of effused fluids. 
Hot fomentations, douches, and stimulant frictions seem to act much in 
the same way. 

There can be no doubt that nature possesses various means of rid- 
ding living structures of the products of disease by modifications in 
that process of cell-formation which constitutes a chief part of healthy 
nutrition. Most of the solid products of inflammation bear evidence 
of their connexion with this process. Those from mucous membranes 
are continually thrown off in a secretion loaded with cells, varying 
from the standard of those of the natural epithelium, to their morbid 
modifications in mucous and pus globules. In cellular and parenchy- 
matous structures, when lymph is effused and subsequently dispersed, 
its removal seems to be effected by a retrograde conversion into dis- 
integrated cells and granules, which gradually disappear. Now in all 
these processes of cell-formation and dissolution, the fatty element 
seems to be an essential ingredient; and as in the healthy removal of 
superfluous tissue, as in the reduction of the structure of the uterus 
after delivery, much of the material undergoes degeneration into fat, so 
these products of inflammation exhibit the same change before they are 
dispersed. These considerations throw some light on the acknowledged 
utility of cod liver oil in promoting the removal and dispersion of the 
products of inflammation. Being absorbed freely into the blood in a 
highly divided state, it soon pervades the products of disease, and by 
dissolving the most solid fats and affording molecular centres for nu- 
merous separating granules, it promotes the process of softening and 
disintegration, and thus brings the effused matters within the reach 
of the processes of absorption and elimination. I believe that there 
are few cases of prolonged inflammatory disease, in which this agent 
will not assist in the dispersion of the products of inflammation, and in 
the re-establishment of healthy nutrition. 

There are cases in which it is necessary to give vent to the accumu- 
lated effusion by surgical operation ; this is illustrated by the incisions 
or acupunctures made in erysipelas, by opening abscesses, and by pa- 
racentesis in empyema, &c. These measures are chiefly required 
when the effused matter is purulent and little susceptible of absorption, 
as well as noxious to the system; but sometimes the mere quantity or 
situation of the effusion, renders the resource of an operation neces- 
sary, in consequence of its immediately endangering life by mechanical 
means, as in acute laryngitis and some cases of pleurisy. 

497. — 9. Increased absorption is manifested in the processes of 
softening, ulceration, and suppuration. I have endeavoured to explain 
how absorption is increased in the midst of distended and effusing ves- 
sels. The veins and lymphatics are free, and in consequence of the 
motion communicated to them from the current of the neighbouring 
and anastomosing branches, they are ready to convey away all the 
fluids that can pass in through their coats. (Guistonian , Lectures, 
1841.) In fact, this is doubtless a provision especially made for the 
removal of superfluous matter, whether effete or new: but the process 
becomes injurious and destructive when it predominates over nutritious 
effusion, and extensively invades the living textures. There is, as Ave 



334 



INFLAMMATION — TREATMENT. 



have seen, reason for the notion that textures do not fall a prey to the 
softening or ulcerative process, unless their vitality is lowered, and 
their nutrition impaired in consequence of a deficient supply, or de- 
fective quality of blood (§ 466, 7 ;) but inflammation produces these 
effects differently in different cases. Sometimes local stimulants and 
general tonics check softening and ulceration by improving the vitality 
and nourishment of the obstructed part ; but they produce the opposite 
effect if the circulation in the affected part is so much obstructed that 
it cannot be quickened. Hence, in phagedenic ulcerations, stimulants 
sometimes check and sometimes aggravate the disease. The increased 
absorption which is a part of the ulcerative process may be arrested 
by diminishing atmospheric pressure, as is done when a cupping glass 
is applied over a phagedenic ulcer; but such an expedient is rarely 
practicable. 

498. — 10. Impeded circulation in the part has been already adverted 
to as contributing, with increased absorption, to the processes of soften- 
ing and ulceration; but its greatest effect is manifested in gangrene, 
or the complete death of a part. In suppuration, also, the affected 
part dies, but it is then removed step by step by absorption, or its cells 
are converted into pus cells, so that its place is occupied by pus, which 
eventually makes its way to the exterior. Of the few agents that may 
be named as serviceable in restoring or improving obstructed circula- 
tion, heat is the most important. It enlarges vessels, especially arteries 
(§ 120,) and facilitates the passage of blood through them ; and although, 
for this very reason, it -is hurtful in sthenic inflammation, and in parts 
where determination prevails, it is very beneficial in the stages and 
forms of the disorder in which obstruction predominates so as to en- 
danger the vitality of the part. Hence the utility of hot fomentations 
or poultices in low forms, or advanced stages of external inflammation. 
In slight cases, frequent applications of heat and moisture may entirely 
remove the obstruction, and restore circulation, and through it the life 
of the part, although the inflammation may have already caused much 
effusion. In other cases, when heat does not remove the obstruction, 
and therefore does not maintain the life of the part, it may neverthe- 
less, by increasing the determination around it, promote its removal 
by hastening and maturing the process of suppuration, which is the 
best by which this end can be effected under such circumstances. In 
a similar way too, heat favours the effusion of lymph, which circum- 
scribes the suppuration and prevents it from spreading or infecting the 
system. And so also, heat and other stimulating applications promote 
the process of separation or sloughing of gangrenous parts (§ 475) when 
they have entirely lost both circulation and life. These latter effects 
may also be often promoted by medicines and food calculated to main- 
tain the vigour of the general circulation. 

499. — 11, The increased circulation around the obstructed part is 
often that constituent of inflammation which causes the most prominent 
symptoms; heat, pain, tenderness, and other indications of excited 
function are commonly dependent on it. Determination has been 
already alluded to as an element of the early stage of inflammation, 
and the reader is referred to that notice (clause 4) for an account of 



FEBRILE INFLAMMATION — BLOOD-LETTING. 



335 



the remedies with which it is best combated. Determination to the 
neighbouring vessels is a part of the extending irritation of inflamma- 
tion, which often sympathetically excites the whole system into fever. 
Its treatment, therefore, should be of the same character with that 
which is suited for inflammation with fever. 

Treatment of inflammation with fever. 

500. The fever excited by inflammation consists chiefly of the con- 
stituents mentioned in the table ; but it will prove more convenient to 
notice them here altogether. They are — (12) Excitement of the heart 
and (13) of the arteries; (14) change in the blood by increase of fibrin, 
and (15) by diminution of the excretions. 

The addition of fever to inflammation very materially modifies the 
treatment. The disorder then to be set right affects not merely the 
inflamed part, and a few other parts that are in sympathetic relation 
with it, but the whole vascular system, the blood and the secretions 
and functions which it supports. The treatment must now therefore 
be general, instead of being merely local; not because the local inflam- 
mation has lost its importance, but because it has become a part of a 
general disease, which reacts upon and sustains it with such energy 
that local remedies are only trivial, if they are not absolutely injurious. 
Thus, when inflammation is backed by febrile excitement of the heart 
and arteries, the stimulant and astringent antiphlogistic remedies (§ 491) 
irritate the distended vessels instead of making them contract. What 
good can local blood-letting do, when there is an excited force behind 
impelling the blood to the inflamed part more rapidly than the external 
oozing can remove it? Derivants also have little power when the 
tension of the whole vascular system is so much raised. Counter-irri- 
tants even prove injurious, by adding another cause of excitement to 
the system. So, too, narcotics can have no control over fever fully 
established, but more commonly prove hurtful by exciting the nervous 
centres, and still further impairing the secreting powers (§ 166.) A 
remedy is wanted that is capable of acting more extensively and gene- 
rally by reducing the action of the heart and arteries, and by dimi- 
nishing the inflammatory character of the blood. The most important 
and powerful agent of this kind is general blood-letting ; next to it 
rank the stronger evacuants, antimony and mercury ; and below these 
in power there are what are called refrigerants and direct sedatives. 
We proceed to notice briefly each of these antiphlogistic remedies. 

501. Blood-letting, if carried far enough, is sure to reduce the action 
of the heart ; for, it may be made to produce syncope. A remarkable 
fact, first pointed out by Dr. Marshall Hall, is, that in inflammatory 
disease a much larger amount of blood may be drawn without producing 
syncope than can be taken during health or in other diseases. The 
following is Dr. M. Hall's table of the results of his investigation of 
the tolerance of blood-letting in different diseases. The numbers re- 
present the mean quantity of blood which flows before incipient syn- 
cope is induced, the patient being in the sitting or erect posture. — 



336 



INFLAMMATION — TREATMENT. 



I. Augmented Tolerance : 

Congestion of the brain 

Inflammation of serous membranes 

Inflammation of synovial membranes ...... 

Inflammation of fibrous membranes 

Inflammation of the parenchyma of organs, (brain, lung, 

liver, mamma, &c.) 

Inflammation of skin and mucous membranes (erysipelas, 

bronchitis, dysentery,) 

II. Healthy Tolerance: 

This depends on the age, sex, strength, &c, and on the 
degree of thickness of the parietes of the heart; but 
it is about . 

III. Diminished Tolerance : 

Fevers, eruptive and others 

Delirium tremens and puerperal delirium 

Laceration or concussion of the brain 

Accidents, before the establishment of inflammation . 

Intestinal irritation 

Dyspepsia, chlorosis 

Cholera 

The explanation of the system's increased tolerance of blood-let- 
ting in inflammation is, I apprehend, to be found in the increased exci- 
tability of the heart and tonicity of the arteries, which maintain a 
sufficient force and tension to preserve the circulation, especially 
through the brain (§ 266,) even when much blood is lost. In asthe- 
nic or atonic diseases, on the other hand, the arteries being lax, and 
ill-fitted to transmit the blood, a smaller loss is felt, and syncope is 
more readily produced. The difference of tolerance in inflammations 
occupying different seats must be referred to the heart's strength and 
the arterial tone being less augmented in some than in others, and 
therefore affords indications of the more or less sthenic (§ 477) cha- 
racter of the affection. The quantity of blood in the system affects 
the heart's action and arterial tension in a similar way; and no doubt 
a more stimulating quality in the blood may contribute to the same 
results. 

502. The object of blood-letting in inflammation is not merely to 
produce syncope, or a temporary impression on the circulation, but 
also a permanent reduction in the excitement of the heart and arte- 
ries; this is best effected by employing different modes of blood-let- 
ting under different circumstances. Where the inflammation is quite 
recent, and the fever has not existed long, a moderate amount of 
blood rapidly taken from a large orifice, or from two arms at once, 
or even from the jugular vein, will often be sufficient to arrest the dis- 
order. The circulation is thus reduced, perhaps to the extent of syn- 
cope ; and when relieved of the pressure and of determination of 
blood, the inflamed vessels soon recover their normal state, or may 
be then caused to do so by the further employment of subsidiary anti- 
phlogistic measures. The benefit resulting from this mode of blood- 
letting in recent cases is sometimes very striking, and the cure is ef- 
fected at a comparatively small expense of blood. 

503. But the case is different when an acute inflammation and fever 
have lasted for two or three days. There is then not merely excite- 
ment, but sundry material changes in the inflamed part and in the 
blood, which tend to keep up the excitement; the inflammation has 



3 XXX. 
U XV. 



^ XI — XIV. 

3 x— xii. 



Vlll. 

*3- 



FEBRILE INFLAMMATION — BLOOD-LETTING. 



337 



become established in the part, and the fever in the system ; and no 
brief impression on the circulation can remove them. If in this state 
a patient be freely bled to fainting, reaction will soon ensue, and re- 
new the fever with increased intensity. Here, therefore, it is neces- 
sary to bleed more slowly and to draw more blood; and instead of 
promoting the occurrence of syncope by the erect or sitting posture, 
it is better to keep the patient in an easy recumbent or reclining po- 
sition, and to watch for the good effect of the bleeding in the soften- 
ing of the pulse, or the relief of the pain or other distressing symp- 
toms. The actual occurrence of syncope is rather to be avoided than 
sought, and it may be prevented by loosening the bandage as soon as 
the lips lose their colour, or the patient complains of feeling sick or 
faint. Thus practised, blood-letting causes a more lasting reduction 
of the active elements of inflammation and fever, diminishes the ex- 
citing and too fibrinous condition of the blood, and although it can- 
not repair the structural changes already produced in the inflamed 
part, it prevents their increase, and puts the structures in a condition 
that is favourable to the curative efforts of nature and to the further 
operation of other antiphlogistic remedies. In the more severe and 
confirmed cases of inflammation it may sometimes be requisite to re- 
peat the blood-letting again and again; the indication for the repeti- 
tion being the return of incompressibility of the pulse, augmented 
heat of the skin, and a new aggravation of all the prominent symp- 
toms. In all such cases, the advantage of the gradual over the sud- 
den mode of blood-letting is very apparent, for where the reducing 
influence of the measure is longest sustained, it is found to be the 
least necessary to resort to it again. In such cases too, cupping or 
free leeching will often prove more effectual than venesection; giving 
more relief to the local symptoms and causing less depression to the 
vital powers. 

Another condition in which it is expedient to draw blood largely 
rather than suddenly is when inflammation is combined with plethora. 
On the other hand, in anaemic subjects, if blood-letting be at all ad- 
missible, the blood must be economized as much as possible; in them 
therefore early depression from the loss of blood should be promoted 
by a posture favouring the occurrence of syncope, and this state may 
be advantageously sustained by the influence of antimony and other 
like remedies. In some cases connected with ansemia the temporary 
withdrawal of a portion of blood from the heart and large vessels 
by means of the process which is termed hamostasis, may prove very 
beneficial; by ligatures being tightly passed round one or more of 
the large limbs, a certain quantity of blood may be arrested in them, 
and for the time withdrawn from the current of the circulation (§ 318 ;) 
this expedient is preferable to dry cupping, because it does not spoil 
the blood that is so arrested to the same extent. 

504. After the excitement of the system has been lowered or re- 
moved by general blood-letting, the local inflammation often has to be 
combated by topical blood-letting, which now not only becomes more 
efficacious in reducing the determination to and distention of the in- 
flamed part, but also contributes to keep down the general excitement. 
In fact, local blood-letting, by cupping or the application of numerous 
22 



338 



INFLAMMATION — TREATMENT. 



leeches, may be carried so far as to be tantamount in effect to general 
blood-letting; and the cases in which it exercises this power are of 
the same nature as those in which slow bleeding answers best. In 
either extremes of age, and in feeble subjects, local bleeding only is 
admissible. It is chiefly suitable too for inflammations which are su- 
perficial and extended, as those of the pleura or peritoneum. It is 
of much less avail in pneumonia, cerebritis, and other inflammations 
of deep-seated or parenchymatous organs. 

Of late years blood-letting may be said to have very much gone out 
of fashion: so much so, indeed, that not a few practitioners of the 
present day openly declare that they never bleed, and very rarely 
apply leeches or cupping. And although the reported experience of 
these enemies to the lancet does not speak conclusively in their favour, 
yet I am ready to admit that in my own practice, the occasions for 
venesection and local blood-letting are much more rare than they 
were twenty or thirty years ago. It may be true that the type of 
disease has undergone a change during that period, being now much 
less sthenic than formerly; but I suspect that the change in practice 
outdoes any such variations in disease, and like fashions in other 
things, tends to an unreasonable extreme. Our improved knowledge 
of the important nature and relations of the blood as an integral 
part of living structure, should teach us to be careful not to waste it 
wantonly: but in our anxiety to avoid bloodshed, we must not forget 
that unrestrained and prolonged inflammation is itself destructive to 
the blood as well as to the solids which it invades, and that a little 
blood judiciously and seasonably withdrawn by depletion, may save 
much blood from being spoilt and wasted by the unchecked progress 
of inflammatory disease. 

505. Of the other antiphlogistic evacuants none are equal in power 
to purgatives, which are great aids to blood-letting, and available in 
most cases of severe inflammation, uncomplicated with gastro-enteritic 
irritation. They operate on so large a surface, (1400 square inches 
according to Meckel,) that they powerfully affect the system, and their 
effect may be even pushed to the extent of producing syncope; but 
such an extreme result is attended with much exhaustion; their too 
prolonged use may also cause intestinal inflammation. The chief 
benefit derivable from purgatives may be obtained by administering 
a few efficient doses at the commencement of the treatment. These 
then aid the depressing effect of blood-letting, remove feculent mat- 
ter, which is often a source of irritation, and clear the intestinal ca- 
nal for the operation of other medicines. The stronger and less 
heating purgatives are to be preferred for this service, such as calo- 
mel, jalap, and salts and senna, combined with tartar-emetic or colchi- 
cum. The union of several, which have a tendency to operate on 
different parts of the canal, answers best. The saline aperients are 
partly absorbed into the blood and there exert catalytically a gentle 
antiphlogistic influence upon its constituents, at the same time that 
the evacuant result is gained. In plethoric subjects, especially if high- 
toned fever is present, it is sometimes difficult to get purgatives to 
act efficiently, on account of the tension of the vascular system, and 
the languor of the absorptive process. After a full bleeding they 



FEBRILE INFLAMMATION — TARTAR EMETIC. 



339 



will, however, resume their power even under these circumstances. 
Or the same end may be gained by combining them with a full close 
of tartar-emetic, for reasons that will be made apparent presently. 

506. Of the various internal remedies for inflammation with fever, 
that which most nearly resembles blood-letting in its effects is tartar- 
ized antimony. It is however far less sure in its operation, and its 
influence is by no means proportioned to the quantity administered; 
yet under its use, especially if it follow blood-letting, the pulse com- 
monly becomes less hard and frequent, the heat of skin is moderated, 
and perspiration ensues, the local symptoms being at the same time 
more or less improved. Sometimes it causes vomiting, more rarely 
purging; but its antiphlogistic operation is most satisfactorily attained 
when these effects do not ensue to interfere with the continued influ- 
ence of the medicine. I have frequently found its utility most marked, 
when it did not cause even nausea or profuse diaphoresis. Tartarized 
antimony, and the milder preparation, James's pow r der, have been very 
long used in this country as febrifuge medicines; and Dr. Marryatt, 
who practised at Bristol in the last century, prescribed large doses of 
the former in the treatment of inflammation. The practice was since 
carried to a greater extent by Rasori, and other Italian physicians, 
who gave from 10 to 120 grains in twenty-four hours. Laennec 
adopted the remedy, but used it in more moderate quantities, pre- 
scribing from one to four grains in some agreeable vehicle every 
second or third hour for six closes; and then intermitting or continu- 
ing it, according to circumstances. In pneumonia and rheumatism, 
he considered it the chief remedy. Most practitioners in this coun- 
try now consider tartar emetic a valuable auxiliary in subduing in- 
flammation, chiefly to be used after blood-letting; or in slighter forms 
of the affection, where blood-letting is inexpedient. I rarely find 
any gain in raising the dose beyond two grains every three hours; 
and in most cases one grain, half a grain or even less, fully answers 
the purpose. The first doses sometimes cause vomiting; but this un- 
pleasant action generally subsides as the doses are repeated, and it 
may be prevented even from the first by giving the medicine in an 
effervescing saline draught, with from four to eight minims of the 
diluted hydrocyanic acid in it. Antimony acts most satisfactorily in 
inflammations of vascular parenchymata and complex structures; such 
for instance as are involved when the lungs and air passages, the tes- 
ticles, the mammas, the skin, and the joints considered as a whole, are 
the seats of the affection. It is less effectual in inflammations of se- 
rous membranes, and altogether unsafe in inflammatory disorders of 
the intestinal canal. It is most beneficial in the early stages of the 
mischief, especially when attended with fever ; but seems to have 
little effect on the products of inflammation. 

The manner in which antimony operates in reducing fever and inflam- 
mation is yet debateable ground. Rasori considered it to be a direct 
sedative or contro- stimulant, diminishing the excitability of the vascu- 
lar system, and so neutralizing inflammation. He supposed the tolerance 
or power of the body to bear large doses of the remedy, entirely to 
depend on the presence of inflammation in the system ; but as Laennec 
has observed, this is not correct; for although patients suffering from 



340 



INFLAMMATION — TREATMENT. 



inflammation are less easily nauseated than others, yet after the dis- 
order has been subdued, they have often continued to take 12 or 18 
grains daily without nausea, or even loss of appetite. Laennec at 
first considered that the medicine acts as a revulsive, through irri- 
tating the stomach; but this view having been made by the Broussaians 
a, ground for opposing the use of the remedy, he latterly attributed 
to it a sorbefacient operation. It seems to me, that the most reason- 
able notion is, that it chiefly acts by diminishing the tonicity of the 
vascular system; and that in addition to this it possesses a catalytic 
power over the blood-constituents, reducing their plasticity and rich- 
ness, and so rendering them less able to keep up adhesive stagnation. 
There can be no doubt that the immediate influence of a nauseating 
close of tartar emetic is upon the vagus nerve and its allies. Through 
this influence it produces sickness, depression of the heart's action, 
muscular relaxation, and retarded breathing. No nausea is produced 
until a portion of the medicine has been absorbed into the blood and 
carried by it to the nerves. It then operates simultaneously upon 
the nerves of the stomach, the heart and the respiratory apparatus. 
Hence the primary power of antimony is purely sedative, and on this 
account it cannot fail to prove a most valuable agent wherever high- 
toned fever is present. So soon as the force of the heart is diminished 
all pressure upon the capillaries is relieved ; and so congestions, de- 
terminations, and stagnations have an opportunity afforded them to 
right themselves — so also the consequent fever begins to decline. 
This is why antimonial treatment possesses so high a reputation in 
the management of such sthenic cases as naturally possess a very rapid 
progress, as for instance croup and certain forms of pneumonia. Its 
operation upon the heart and respiratory muscles is no less sudden 
and powerful than that of these very formidable disorders. The ca- 
talytic action on the blood is of necessity a much slower and less 
available one, than that upon the organic nerves, but when adminis- 
tered in doses that are much too small to possess any nauseant power, 
it gradually impoverishes the nutrient liquid. It is probable that 
when thus employed in small doses, it is entirely eliminated from the 
circulation through the mucous membranes and the skin. In this way 
it acts as a gentle evacuant and derivative. It is hence in constant use 
as an expectorant and diaphoretic in various febrile and inflammatory 
disorders (§ 122.) Small doses certainly relax the pulse and skin, 
and, where there is no fever, produce perspiration without stimula- 
ting. They also seem to increase the biliary and intestinal secretion. 
In inflammation and fever, larger doses are required to produce the 
same result, because then the sedative influence must first come into 
play to reduce the force a tergo, before the catalytic and eliminant 
influence can be secured. In this way the deranged circulation is 
equalized and quieted, the determination to, and distention of, the in- 
flamed part are diminished, and the vessels generally are placed in 
a condition favourable to the performance of their natural offices of se- 
cretion, which extreme tension had before interrupted. It is quite pos- 
sible too that deoxidizing power, such as has been before alluded to 
(§ 494) may have some connexion with the result, and this would in 
some degree account for the greater tolerance of the medicine in in- 



MERCURY AND OPIUM — OPERATION. 



341 



flammatory disease, which involves a process of hyperoxidation. This 
Suggestion is however at present only based on hypothesis, and might 
with advantage be tested by experiments on the lower animals. 

507. Another great remedy in inflammation is mercury, given alone 
or combined with opium. The combination of calomel and opium 
was first employed by Dr. Hamilton of Lynn Regis; and the rules 
which he laid down for its use have hardly been since improved on. 
After a sufficient venesection and a full purge, he administered from 
one to five grains of calomel with from one-fourth of a grain to one 
grain of opium every six, eight, or twelve hours. When much fever 
was present with dryness of skin, he added a little tartar emetic and 
camphor. If no relief ensued in twenty-four hours, venesection was 
repeated. Most practitioners admit the power of this remedy, al- 
though some ascribe its efficacy to the mercury, others to the opium: 
and the proportions in which these medicines are united have accord- 
ingly been varied considerably. The beneficial effects of this remedy 
depend generally, but not entirely, on the mercury affecting the sys- 
tem, as is manifested in adults by fcetor of the breath, and tenderness 
and swelling of the gums; and in children, by spinach-like evacua- 
tions from the bowels. Amendment is, however, often evident before 
these results take place. They are merely the signs of the full satu- 
ration of the blood by the medicinal agent. Its presence in a much 
slighter degree is commonly curative. In iritis, the influence of mer- 
cury is made visible by the removal of the effused lymph; so that it 
obviously in some way promotes absorption, as well as prevents effu- 
sion. The same " sorbefacient" operation is seen in the effect of 
mercury in removing the callous margins of indolent syphilitic ulcers, 
and in promoting the spread of phagedenic ulcers. Dr. Farre thinks 
that mercury destroys the red corpuscles of the blood, and causes in 
the system a disposition to erythematic inflammation, which is incom- 
patible with the phlegmonous or plastic phase of the disorder; but 
this view is opposed by the fact that lymph is thrown out, and that 
granulations form and healthy ulcers heal during mercurial action. 
A brief review of the modus operandi of a combination of mercury 
and opium may be advantageously taken here, for although there is 
no certainty that the matter is fully and satisfactorily understood, a 
statement of what is best known of the effects of these medicines, 
may prove a valuable guide in their administration and management. 

The opium is useful in preventing the mercury from purging, and 
in subduing the nervous irritation attendant upon inflammation, which 
is as we have seen one cause of that sympathetic excitement which, 
when complete, constitutes fever (§ 440.) This salutary effect of 
opium is sometimes gained when it is administered alone after the 
vascular excitement has been subdued by a large blood-letting, as well 
as in cases in which nervous irritation forms a prominent element of 
the disease: here a full dose of opium subdues the remains of the in- 
flammation better than any other antiphlogistic remedy ; it seems to 
paralyze those sympathies which are concerned in renewing or main- 
taining the excitement of the inflammatory fever. So, too, when com- 
bined with mercury, the opium exercises the same narcotic influence ; 
whilst the mercury obviates the opiate's astringent effect on the se- 



342 INFLAMMATION — TREATMENT. 

creting organs (§ 66, 173.) The mercury also augments the biliary 
and intestinal secretions; sometimes inducing copious mucous and 
bilious evacuations, as antimony is eliminated from the blood mainly 
by the skin and pulmonary mucous membranes, increasing their se- 
cernent activities in the process. Mercury is chiefly thrown out 
through the cells and vessels of the liver and the intestinal mucous 
membranes augmenting their functions in a similar way. M. Leh- 
mann has detected the mercury in the alvine excretions of persons 
who have had it in their blood, and M. Buckheim found it in the bile 
of dogs, to whom he had given it. From the result which is obvious 
to direct observation in iritis, it is clear that mercury has the power to 
facilitate the solution and removal of the effused lymph. How it ef- 
fects this is yet uncertain: but probably by catalytically calling up 
changes in the condition of the blood, through which the quantity of 
the fibrin and white corpuscles, — the constituents whose presence is 
mainly concerned in inflammatory processes, — is diminished. Mercury 
certainly is chiefly useful where the blood is very much buffed, and 
where there is a tendency to copious fibrinous effusions, as in inflam- 
mations of serous membranes and croup. Calomel and opium have 
little influence over high inflammatory fever; the system thus excited 
generally resists the mercurial action, probably on account of absorp- 
tion being then arrested, or very imperfectly performed. The re- 
medy then has no further sedative effects than such as proceed from 
its immediate action on the intestinal canal: and excepting so far as 
it is required for this sedative purpose, the combination is not well 
adaptecl for the earliest stage and most active forms of inflammation. 
In these circumstances the preliminary of blood-letting is requisite, 
and then the mercury is best united with antimony : if fever returns 
during the action of mercury, blood-letting or active purging may be 
again necessary for its reduction. In fact the combination of calomel 
and opium is less antiphlogistic, aud more alterative in its operation 
than blood-letting, or antimony: it is inferior to them in the power 
to reduce inflammatory fever and active inflammation; but it is supe- 
rior to them in arresting and removing the more plastic products of 
the process. Besides the comparatively slow influence exerted by 
mercurial preparations generally, there are however others which are 
peculiar to calomel, and which render it a most effectual remedy even 
in active inflammations ; when given in large doses (from 5 gr. to 
it acts as a powerful cholagogue, and often causes the evacuation of 
dark green matter, which the examinations of Dr. G. Bird have shown 
to resemble the colouring matter of the blood, rather than bile, in 
composition. The operation of calomel employed in this way does in 
truth resemble that of blood-letting, being much more actively anti- 
phlogistic than when it is used in small doses. This mode of exhibit- 
ing it has been extensively adopted in India, and has also been taken 
up in this country with much success by Dr. Chambers. The chief 
evil attaching to it, is its tendency to induce inflammation of the large 
intestines and dysenteric straining; on this account the plan cannot 
often be long persisted in. 

508. Various saline medicines, such as nitrate of potass, and the al- 
kalies combined with vegetable acids, deserve mention as serviceable 



SALINES — DIURETICS — COUNTER-IRRITANTS. 



343 



auxiliaries in the treatment of inflammatory fever, although they are 
comparatively inefficient when employed alone. Their dilute solu- 
tions allay thirst, and seem to cool the fever; hence they have obtained 
the title of refrigerants. It is uncertain how far they may operate 
by diminishing the cohesion of the corpuscles and the excess of fibrin 
in the blood (§ 438.) It is highly probable that they do possess the 
power of rendering the fibrin less adhesive and plastic, and Mr. Gul- 
liver states that he has been able to detect their influence in prevent- 
ing the adhesion of corpuscles in inflammatory blood. But some of 
their good effects may certainly be traced to their augmenting the se- 
cretions, particularly the renal (§ 256,) as they are' eliminated from 
the circulation. They are all more or less diuretic; and most of them 
also supply an alkaline base, which unites with the lithic and lactic 
acids formed in the blood, and so facilitates the separation of these 
matters by the kidneys. Colchicum and digitalis are sometimes 
reckoned among antiphlogistic remedies; but in common inflamma- 
tion they are of very inferior power. In the absence of high-toned 
fever colchicum exerts a special action on the secretion of the liver, 
somewhat resembling that of mercury, and also augments the elimina- 
tion by the kidneys (§ 257 :) digitalis too, operates as a diuretic, and as 
well as a sedative on the irritability of the heart: but during severe 
inflammation these effects are scarcely attainable by doses which it is 
prudent to administer. The same remark is applicable to hydrocyanic 
acid and various preparations of aconite. There can be no question 
that both of these agents are capable of depressing the action of the 
heart, and thereby of reducing the force of the circulation; but it 
would require large and dangerous doses to produce this effect during 
the excitement of active inflammation. 

509. The utility of counter-irritants as a remedy for several of the 
elements of local inflammation has been already noticed (§493, 498;) 
but their operation is positively injurious in sthenic inflammation du- 
ring the prevalence of fever. They then add to the excitement of the 
system ; and in proportion to the local inflammation which they excite, 
they prove a fresh source of inflammatory changes in the blood (§ 438.) 
But after the fever has subsided under the influence of remedies, or has 
been exhausted by time, the advantage of counter-irritants predomi- 
nates. The seat of their application ought, however, to be somewhat 
determined by the excitability of the vascular system; where this is 
great, the counter-irritation should be more remote from the seat of'in- 
flammation ; where it is comparatively slight, blisters may be applied 
in close vicinity to the affected part. Blisters and suppurating counter- 
irritants, which cause copious discharge, are the most useful remedies 
of the class ; they tend to exhaust the lingering remains of inflammation 
and to promote the removal of matters that have been effused during 
the active stage of the process. Such measures become our chief reli- 
ance when inflammation inclines to a chronic state, or when it has left 
such structural changes as cannot be speedily set right. 

510. The antrplilogistic regimen comprises the avoidance of all cir- 
cumstances and agencies that are capable of exciting or fatiguing the 
body or mind of the patient. Absolute rest in bed in a very quiet, 



344 



INFLAMMATION — TREATMENT. 



rather dark, yet cool and carefully ventilated apartment, greatly fa- 
vours the restoration of tranquillity to the circulation. The exclusion 
of noise, bustle, and other sources of excitement, and the careful remo- 
val of all irritating excrementitious matters, are essential conditions to 
its observance. 

The antiphlogistic diet comprehends a similar avoidance of all irri- 
tating, and stimulating, as well as the more nourishing articles of food. 
The proteinaceous materials, meat, eggs, and in severe cases, even 
bread and milk must be prohibited, besides all oily nutriment, which 
tends to increase the heat of the body : amylaceous, gummy, and sac- 
charine matters may be taken sparingly, and are best given in thin 
fluids, such as barley-water, tea, weak gruel, and arrow-root. The 
thirst that is generally present, suggests the free use of diluents, which 
are serviceable in cooling the body, and in promoting the action of 
diuretic, diaphoretic, and other evacuant medicines; but even these 
bland fluids, if used to excess, tend to oppress the stomach and disturb 
the heart's action; and also prove hurtful by augmenting the bulk 
of the circulating fluid. When fever is present, the total loss of appe- 
tite is a sufficient indication of the necessity for abstinence from food; 
the stomach commonly will not retain, or if it does, will not digest, any 
but the weakest kinds of nutriment ; but this is not the case in every at- 
tack of inflammation, although self-denial and restraint may on that 
account be only so much the more imperatively demanded. 

511. Exhaustion. — Depression from poison. .(See Table, 16 and 
17.) The exhaustion which is consequent upon the long-sustained 
excitement of inflammation and fever, often renders stimulants and 
tonics, as well as a generous diet, necessary in the after treatment ; 
but the greatest circumspection must be exercised in making sure that 
these agents are employed in proportion to the wants of the case, and 
that they are not used so early or pushed so far as to rekindle the 
inflammation afresh, or to produce other disorder in the weakened 
organization. No diffusible stimulant is more generally or safely ap- 
plicable at this juncture than ammonia, which may be most conve- 
niently exhibited by adding its carbonate to the saline draught. It 
seems possible that its utility may in part depend on its supplying 
the azote necessary for the conversion of amylaceous and saccharine 
nutriment into albuminous or gelatinous principles, as Dr. Alison has 
conjectured. Alcohol and ether obviously act by furnishing a ma- 
terial that can be employed in the production of animal heat, so that 
the oxygen in the blood is prevented from preying too much on the 
textures. Similar aids are also required, to support the system against 
the pernicious influence of purulent or gangrenous matter, that re- 
sults from the inflammatory process. Even in cases of simple suppu- 
ration, the occurrence of the premonitory rigors, and the diminished 
strength of pulse and heat of skin, point out the time when the re- 
ducing plan is best exchanged for one more supporting; but the ex- 
tent to which this change is made should depend on the character of 
the symptoms, and on the efficiency with which nature is attempting 
the process of limiting the mischief to the destroyed part. When 



REMEDIES FOR DEPRESSION. 



345 



suppuration has once commenced, there is no probability of its retro- 
gression; and therefore the obvious indication is to promote its com- 
pletion and to prevent as far as practicable its extension, and the 
diffusion of the pus through adjoining parts and through the system. 
This object is best secured by the use of local stimulants, especially 
heat combined with moisture. Such applications promote determi- 
nation of blood to the part, whereby the formation of pus globules 
is quickened, as is also the solution and absorption of the compressed 
fibrin and tissues (§ 461,) whilst surrounding vessels, inflamed but 
less obstructed, are engaged in throwing out a barrier of lymph, 
which retains its vitality and resists the solvent action and advance 
of the pus in all directions, except that in which the textures yield 
most, and through which it is ultimately to find vent. The local 
treatment of gangrene also comprises more or less the use of stimu- 
lant applications to aid the process of separation, or sloughing, of 
the dead from the living parts. It is probable that in all cases, some 
purulent or gangrenous matter finds its way into the circulation ; 
therefore, in addition to stimulants and tonics, antiseptics (such as 
chlorinated liquids, nitro-muriatic acid, chlorate of potass, chloro- 
form, and creasote) are sometimes with advantage given internally 
to counteract the septic influence on the blood; but above all things 
the secretions are on this same account to be kept free, to promote 
the elimination of the morbid matter (§ 260, 443,) the foul nature of 
which is commonly evinced by the fcetor and disordered appearance 
of the feces and urine. For a similar reason, foul suppurating and 
gangrenous sores require to be dressed frequently, and their discharge 
corrected and promoted by antiseptic and alterative applications. 
No application to gangrenous or sloughy sores is more efficacious than 
recently prepared charcoal. Its power to correct putridity and fcetor 
has been long known : but Dr. Stenhouse has shown that it does more 
than this for parts in a state of gangrene. It not only absorbs and 
decomposes all putrid effluvia and discharge, but its contact hastens 
the decomposition and removal of the dead tissue; it is therefore 
most beneficial in promoting the removal of sloughs. I lately had a 
patient with extensive sloughs on the legs, consequent on dropsy : 
the fcetor was overpowering, and the system seemed to be rapidly 
sinking under the deadly influence of the mortification ; when after 
the parts were freely sprinkled with charcoal powder, the whole evil 
seemed immediately checked: the fcetor ceased, the constitutional 
depression diminished ; the sloughs gradually diminished and sepa- 
rated; and the wounds granulated and healed in the course of a few 
weeks. I have also found much advantage from the use of enemata 
of fine charcoal powder with water and a little laudanum, in severe 
cases of dysentery and diarrhoea with very offensive discharges, when 
there was reason to suspect the large bowel to be in a sloughy state. 

18. Removal of the products of Inflammation. 
512. The serum, liquor sanguinis, and healthier kind of fibrin and 
exudation corpuscles (§ 424,) are removed after they have been effused 
from the vessels by the natural process of absorption (that is, osmosis 
into the adjoining vessels, the fibrin having been previously made so- 



346 



INFLAMMATION — TREATMENT. 



luble by conversion into tritoxide of protein, or commuted into fluid 
fat,) aided by the influence of such remedies as have been already men- 
tioned, particularly mercury, iodine, iodide of potassium, colchicum 
and other diuretics, and the application of blisters and other counter- 
irritants. As in all probability a free circulation of blood favours the 
removal of effused solids partly by further oxygenating them, the idea 
has been suggested that the process may be quickened by the internal 
exhibition of agents which contain a large proportion of oxygen in 
loose combination. Nitric acid answers to this description ; and whether 
this be one of the ways in which it acts or not, I can affirm, from much 
experience in its use, that it is certainly the best medicine I know for 
hastening the state of convalescence from inflammation. In doses of 
20 to 30 minims three or four times daily, administered in some aro- 
matic or mild bitter vehicle, it often cleanses the tongue and improves 
the appetite, circulation, and strength. Its utility is somewhat limited 
by its tendency to irritate the bowels. But this result very rarely 
occurs. The products of inflammatory effusion in external parts are 
sometimes more speedily dispersed by the agency of what are called 
discutients; these are generally slightly stimulant applications, such 
as warm spirit lotions, or solutions of hydrochlorate of ammonia, common 
salt, or iodide of potassium; and in more chronic cases, liniments con- 
taining mercury, iodine, ammonia, and spirit, used with friction. They 
operate much in the same way as the various other remedial influences 
already alluded to, as for instance by promoting a free current of blood 
through the part without producing distention, and so facilitating ab- 
sorption; by diminishing the atonic congestion left by inflammation; 
by increasing secretion or exhalation ; and by compressing the struc- 
tures. The restoration of a vigorous state of the circulation and ex- 
creting function is often necessary to effect the removal of copious ef- 
fusions and deposits consequent upon inflammation. Thus I have often 
observed that pleuritic effusions show no signs of dispersion until the 
strength of the body begins to return under restorative treatment. 
From the researches of Mr. Gulliver and others it appears that the 
longer an inflammatory product remains without becoming organized, 
the more does it abound in particles or granules of a fatty character, 
consisting of margarin and olein. This change, which is like that 
which forms atheromatous matter in arteries, and aplastic tubercle 
elsewhere, probably depends on a spontaneous conversion analogous to 
the production of adipocire from flesh kept moist and secluded from 
the action of the air. To prevent such a result, and perhaps to arrest 
it when once begun, or even to remove the solid deposits which have 
been laid down, we naturally look to measures that increase the free 
circulation of arterial blood in and around the part; which, either by 
the agency of the oxygen or of other solvent principles which the blood 
contains, may possibly disperse and carry away the fats, and other 
solid deposits. Probably in this way the cod liver oil operates in the 
removal of the products of inflammation: being peculiarly fluid and 
diffusive it penetrates the tissues and dissolves the more solid fatty 
matters, into which the products of inflammation degenerate. This 
subject will be again under notice when speaking of Degenerations and 
Morbid Deposits. 



VARIETIES — CHRONIC CONGESTION. 



347 



TREATMENT OF VARIETIES OF INFLAMMATION. 

513. The sthenic (§ 477) form of inflammation requires the whole 
array of antiphlogistic remedies to be directed with energy against it. 
The prevalence of determination, active vascular excitement, and the 
over-fibrinous condition of the blood, demands the free use of blood- 
letting, calomel, purgatives, and antimony, at the onset; and the full 
operation of mercury if the disease continue. In asthenic inflamma- 
tion, on the other hand, blood-letting is ill borne, and can only be 
practised locally, if at all ; the chief reliance must therefore then be 
placed upon antimony or mercury, and blisters, which, in the absence 
of high fever, may be employed at even an early period. The diet, 
although light, should not be too spare, and may include such nutri- 
ment as animal broths, milk, farinaceous food, and sometimes fish or 
white meats. Mild stimulants, particularly ammonia, may sometimes 
be required, in order to enable the system to complete the processes 
of protection and elimination which are always needed during inflam- 
mation (§ 443, 4.) 

514. Acute inflammation (§ 478) demands a very prompt use of anti- 
phlogistic remedies; but the choice of the particular kinds and the ex- 
tent to which their action is to be pushed, depends on whether the in- 
flammation be sthenic or not. Subacute inflammation is generally of 
the asthenic form ; and being less severe, as well as slower in its pro- 
gress and effects, it does not require such active treatment as that of 
higher tone. It must not, however, be neglected; for its obscurity 
sometimes renders it dangerous: and it not uncommonly does serious 
injury to both function and structure in the most insidious way. Its 
habit of long continuance and its liability to recur, render it necessary 
to continue some degree of antiphlogistic treatment for several weeks. 
When it has lasted thus long, it tends to become more asthenic, and 
the lowering antiphlogistic remedies are no longer serviceable ; some- 
times it is then proper even to call in the aids of tonics and improved 
diet, whilst the local mischief is attacked by counter-irritants. Mer- 
cury with opium is generally one of the most useful remedies in sub- 
acute inflammation. 

515. Chronic inflammation recedes still further from the inflamma- 
tory type, and borders more on congestion or disease of nutrition. 
The absence of fever usually supersedes the necessity for employing 
the stronger antiphlogistic remedies — and those suited for local inflam- 
mation are sufficient; general blood-letting is needful only when ple- 
thora also is present ; and even local blood-letting should not be too 
freely employed, for it tends to weaken a system which is already too 
feeble. Counter-irritants are constantly useful ; and their application 
should be varied according to the seat and extent of the inflammation. 
In affections of serous membranes, a succession of large blisters answers 
best. For chronic inflammations of parenchymatous organs, and ul- 
cerations of mucous membranes, suppurative counter-irritants, and se- 
tons, are of more avail. Mercury and the other alterative medicines, 
especially salines and the iodide of potassium, are often useful. Mer- 
cury answers best in the more sthenic cases where there is effusion of 
lymph, leading to tough thickening and induration of textures. Iodide 



348 INFLAMMATION — TREATMENT. 

of potassium is better adapted for chronic inflammation of an asthenic 
character, where there is reduced blood and strength, with tendency to 
ulceration, suppuration, or aplastic deposits. It is often requisite to 
keep up the general strength by mild tonics, such as sarsaparilla and 
the light bitters, and to allow a nourishing, but not stimulating diet, 
regulated according to the digestive powers of the patient. Careful 
attention to the state of the excretions is particularly necessary. 
Courses of mineral waters, and change of air by gentle travelling, are 
also often serviceable in chronic inflammations. 

516. In congestive inflammation (§ 480,) the treatment for conges- 
tion should be combined with that for subacute inflammation. If the 
subject be plethoric, general blood-letting is advisable; otherwise local 
bleeding and various derivants or revulsives, among which cupping 
and dry cupping, or hemostatic ligatures (§ 318, 503) are the most 
effectual. Rubefacient applications, such as large mustard poultices, 
and strong ammoniacal or mineral acid liniments, applied over a large 
surface, are of considerable efficacy; and their use can be repeated 
daily and varied in diverse ways for a long time. Mercury and anti- 
mony are both of considerable value in the more active stage of con- 
gestive inflammations : the former especially for inflammations of the 
abdomen, the latter for those of the lungs. In the absence of much 
irritation, iodide of potassium, mineral acids, and even quinine, may 
avail in obviating the congestive condition. So, too, when secreting 
structures, like the liver, kidneys, and mucous membranes, are princi- 
pally concerned, stimulants which excite their various secretions will 
do the same thing. In congestive inflammation, as in long continued 
congestion, the blood suiters from stagnation in the affected part, and 
being spoilt (§ 191) is very apt to prove a cause of contamination to 
the rest of the circulating fluid in the body. Hence the propriety of 
using the various depurative remedies which increase the excretions, 
&c, and of resorting to iron, quinine, and nourishing food during the 
convalescence. Further particulars, that have relation to this subject, 
will be found where the treatment of congestion is considered (§ 313, 
et seq.) 

517. The appropriate treatment for 'phlegmonous inflammation 1 is 
generally such as is suited to the sthenic form. Erysipelatous inflam- 
mation being as commonly asthenic, is not benefited by active anti- 
phlogistic measures ; and in some cases it is necessary even to adopt 
quite an opposite treatment, and to give ammonia, wine, bark, &c. : 
this is when the influence of the specific poison (§ 482) predominates. 
In other cases, the reaction against this influence is very vigorous, 
and requires to be held in check. Generally the administration of a 
saline, combined perhaps with small doses of tartar emetic, keeping 
the secretions free, and applying warm fomentations to the affected 
part, answer best at first ; and these measures must in a few days be 
replaced by giving chloric ether, ammonia, wine, and bark or quinine, 

1 This term is used here in the sense in which Cullen employed it, as opposed to 
erythematic or erysipelatous. I mention this, because boils, or furuncular inflammations, 
are commonly of an asthenic character, and not unfrequently require that measures 
should be adopted to support the system. 



VARIETIES' 



: — PHLEGMONOUS 



: — diphtheritic. 



349 



with improving nourishment. 1 A more direct counter-agent to the 
poison in the blood, is a desideratum ; but scrupulous cleanliness and 
careful regulation of temperature and ventilation, with a free use of 
chlorides or charcoal in the room, to a great extent prevent the disease 
from spreading in hospitals and sick chambers where there are effluvia 
from sores or wounds. Punctures and incisions, which relieve the in- 
flamed part by causing a discharge of blood and serum ; cauterization 
by nitric acid or nitrate of silver, which arrests the progress of the 
disorder by exciting a different kind of inflammation — and the appli- 
cation of mercurial ointment, which seems to modify its character, — 
constitute the chief kinds of local treatment that have been found useful 
for erysipelas. 

518. Pellicular or diphtheritic inflammation is usually of an asthenic 
character, and is little benefited by blood-letting, but may be counter- 
acted by mercury, the grand remedy for all inflammations effusing 
lymph; and by local astringents, or even caustics, which powerfully 
excite the vessels, and so change their action. Thus the direct appli- 
cation of nitrate of silver, in substance and in solution, of hydrochloric 
and diluted nitric acids, (one part to three or four parts of honey used 
with a brush,) and of finely powdered alum, has been used with advan- 
tage in diphtheritic sore throat. In the croupy inflammations of chil- 
dren, the most effectual remedies are, calomel freely given, antimony, 
and certain expectorant or attenuant medicines, which promote the 
more liquid secretions of the affected membrane. The aphthous in- 
flammation of children is readily subdued by the application of a satu- 
rated solution of borax, or of a weak solution of sulphate of zinc, em- 
ploying at the same time magnesia and mild mercurial aperients to 
correct the secretions of the alimentary canal. A weak solution of 
tannic acid is also often serviceable in removing erythematic inflam- 
mations of the mouth and fauces. 

519. Hemorrhagic inflammations (§ 484) are often of the congestive 
kind; and the hemorrhage arises from the excessive distention of ves- 
sels, as instanced in the hsematemesis that sometimes precedes gastritis, 
the bloody discharges of dysentery, and the hematuria which occasion- 
ally ushers in inflammation of the pelvis and tubes of the kidney (pye- 
litis.) I have often remarked that the hemorrhagic tendency exhibited 
in purpura, and sometimes combined with inflammation in lichen livi- 
dus, and ecchymosed erysipelas, is connected with congestion and 
torpid action of the liver (§ 171,) and that it is accordingly corrected 
by mercurial and saline aperients, followed by nitric or nitro-muriatic 
acid. 

1 Erysipelas of the head and scalp is the form of the disorder -which falls most 
commonly under the observation of the physician; and although it is often attended 
vntli formidable symptoms, I have very rarely known it to prove fatal. All the cases 
(twenty in number) which have been under my care at the hospital, recovered in a period 
varying from one to four weeks, under the general treatment recommended above, with- 
out any other local measures having been adopted than the use of fomentations, where 
the patient likes them, very rarely a leech or two to the temples, and poultices to any 
succeeding boils. In private practice stimulants and tonics seem to be necessary at an 
earlier period and to a greater amount than in hospitals ; and I do not remember to have 
seen a case of erysipelas, uncomplicated with organic disease, prove fatal when this 
mode of treatment was unremittingly pursued. 



350 



INFLAMMATION — TREATMENT. 



520. Scrofulous inflammation (§ 485) being generally asthenic, is 
little benefited by blood-letting or other active antiphlogistic measures. 
Its disposition to produce at once cacoplastic and aplastic effusions 
makes it important that it should be subdued, if possible, at an early 
stage, whenever it occurs in situations in which the formation of curdy 
pus or tuberculous matter would be injurious. In scrofulous inflamma- 
tion of the lymphatic glands, warmth, with moisture and discutient ap- 
plications, (solutions of muriate of ammonia, of iodide of potassium, and 
warm vinegar,) often succeed in dispersing the swelling before it comes 
to suppuration. In the internal inflammations of scrofulous subjects, 
such as of the lungs, glands, and joints, local depletion is generally 
advisable, followed by free counter-irritation of a character that will 
cause an external discharge of pus. Dr. O'Beirne and others recommend 
a full mercurial course for scrofulous inflammation ; but this I consider 
admissible only in the earliest stage of the disease, and in its most active 
forms; for I have found (and I believe it is consonant with the experi- 
ence of most practitioners) that mercurialization greatly injures the 
constitution of scrofulous subjects, tends in them to degrade the products 
of inflammation, and promotes softening and ulceration in textures 
where deposit has already taken place. It seems to me, that it is 
rather asthenic or chronic inflammation (§ 479,) occurring in subjects 
who are not scrofulous, that is benefited by mercury, than that which 
is peculiar to the scrofulous diathesis. Preparations of iodine, espe- 
cially the iodide of potassium, are more suited for combating low scro- 
fulous inflammation ; their operation is commonly salutary, when the 
constitution has in it the taint of scrofula. 

The main source of the peculiarities of scrofulous inflammation, and 
therefore the chief consideration to be kept in view in determining the 
peculiar treatment, is the diathesis or constitutional fault; this seems 
to consist in a degraded condition of the plasma, or nutritive material of 
the blood (§ 211,) often connected with a deficiency of red corpuscles 
(§ 185;) an invigorating and nourishing treatment and regimen are 
therefore especially indicated (§ 218, 219,) and may sometimes be 
beneficially adopted even when low inflammation is present; this being 
at the same time attacked by counter-irritation or other local antiphlo- 
gistic measures. Therefore the best remedies in scrofula are tonics, 
nourishing diet, and such other means as are calculated to improve the 
nutritive function and general health. Even the medicine that has 
attained the highest repute in its treatment, may be considered in the 
light of a nutriment. I allude to the cod liver oil, which has long been 
employed on the Continent, and in a few places in this country, but 
only within the last ten years has been received into general use. Its 
extensive adoption depended much on the improved method of pre- 
paring it discovered by British chemists, and which procures it fresh 
from the livers of the fish without taint or nauseous odour. Having 
ascertained that the oil thus pure and tasteless, was at least as effica- 
cious as the nauseous brown stuff' previously tried, I recommended it 
strongly to the profession, and it is now very extensively used. Com- 
mencing w r ith the close of a teaspoonful twice or thrice daily (imme- 
diately after each meal,) and gradually increasing this to a tablespoon- 



VARIETIES — GONOMIHCEAL AND SYPHILITIC. 



351 



ful, this medicine produces an astonishing improvement in most scrofu- 
lous patients. It seems to give anew impulse to nutrition; for an 
amendment is soon perceived in the accession of flesh, in the freshen- 
ing of the complexion, and in the augmentation of the strength; com- 
monly the pulse is moderated, the appetite increased, and more or less 
amelioration is manifested in the local inflammation. Thus scrofulous 
swellings diminish and even disperse under its influence; enlargements 
of joints are reduced ; ichorous sores are caused to secrete a more 
lauclahle pus; the profuse discharge from abscesses and vomicae is les- 
sened; and consequently hectic fever, and night sweats and its other 
concomitants are checked. The chief practical difficulty that has to 
be encountered in its employment, is its tendency to disorder the sto- 
mach and liver: the latter I sometimes find to become remarkably en- 
larged during its exhibition. The utility of cod liver oil in tuberculous 
disease, and its mode of action, will be considered under the head of 
cacoplastic and aplastic deposits. The other medicinal agents that 
have been found to possess the most corrective power over the scrofu- 
lous diathesis, are the iodides of potassium and iron, chalybeates gene- 
rally, bitters with alkalies, bark, or quinine, and mineral acids. Equally 
important in its treatment are residences in pure and mild air, especially 
near the sea or on mountains ; warm clothing ; regular exercise, friction 
upon the skin, and the adoption of other measures that promote the 
superficial circulation; warm sea bathing, or cold (when the patient 
can bear the shock and chill) (§ 79,) followed by friction; a good pro- 
portion of wholesome animal food, and a careful regulation of the state 
of the excretions. All these are of great efficacy where there is a ten- 
dency to this form of disorder, and they are often useful even after 
inflammation has produced structural disease ; for they may then do 
much to prevent its increase, and to assist nature in removing or ren- 
dering inert, the cacoplastic, or aplastic matter that has been deposited. 

521. The peculiarity in the treatment required for rheumatic and 
gouty inflammation, consists chiefly in the need for the elimination 
from the system, of the morbid matter which is the cause of the de- 
rangement (§ 251 — 254.) The remedies which are the best adapted 
to promote this object have been already mentioned (§ 252, 254.) But 
it must be remembered, that the inflammation and fever present in rheu- 
matism or gout may be so high and sthenic, as to require active anti- 
phlogistic measures before colchicum or mercury can be made to act ; 
this is particularly the case in acute rheumatism, in which inflamma- 
tion is excited in many parts at once; and in which probably as a con- 
sequence (§ 438,) the blood becomes surcharged with fibrin. Here 
general blood-letting is useful, not in order to remove the cause of the 
inflammation, but to arrest the inflammation itself. If after blood- 
letting, the material cause of the rheumatism is still abundant in the 
blood, which is commonly the case, it is then advisable to give colchi- 
cum with alkalies, iodide of potassium, or nitre in large quantities and 
much diluted, (Gendrin,) or lemon juice, (Owen Rees,) or bicarbonate 
of potass, (Garrod, 1 ) and to continue the employment of the remedy 

1 Med. Chir. Trans., 1855. Dr. Garrod relies entirely on the nse of the bicarbonate 
of potass given in such quantities (gss or ^ij in giss water every hour or two hours) as 



352 



INFLAMMATION — TREATMENT. 



for some time, until the morbid matter shall have been sufficiently eli- 
minated. In asthenic cases, the use of bark, quinine, and other tonics, 
often proves serviceable in improving the tone of the vessels after the 
irritation and exhaustion which the disease and its treatment have pro- 
duced (§ 174.) 

The infectious character of gonorrhoea and syphilis proves the speci- 
fic nature of their cause ; but it is only with regard to the latter that 
we can speak of a specific remedy. How mercury cures syphilis is 
quite uncertain. It is not by any property directly destructive to the 
virus ; for the disease cannot be prevented from appearing by mercu- 
rial action ; and when present, is not always cured by it. It is more 
probable that mercury acts as an alterative, by removing the callous 
indurations of syphilitic sores and swellings, and by increasing the se- 
cretions, and thus gradually eliminating the syphilitic virus from the 
system. It is now well ascertained that other remedies which promote 
absorption and secretion, also favour the cure of syphilis, especially 
the iodide of potassium. Gonorrhoeal inflammation generally tends to a 
spontaneous cure in a few weeks' time, but this may be accelerated by 
adopting mild antiphlogistic and demulcent measures at first, and by 
using astringent injections and terebinthinate medicines subsequently. 

to induce an alkaline state of the urine. In lny hospital practice in rheumatism I made 
several comparative trials of carbonated alkalies, alone, and conjoined with colchicum; 
and the result was decidedly in favour of the latter combination; but I never pushed the 
alkaline treatment so far as Dr. Garrod advises. Under treatment with bicarbonate of 
potass, Dr. G. found the convalescence established in from four to ten days. Under 
treatment chiefly with alkaline carbonates and colchicum, the same result was attained 
in five or six days. The success of the two methods seems therefore to be nearly the 
same ; but I must acknowledge that colchicum is more apt to disagree than the large 
doses of bicarbonate of potass appear to do. I should expect that the latter must con- 
siderably impoverish the blood, and that a course of chalybeate medicine, as sometimes 
employed by Dr. Garrod, would be generally proper after convalescence. 



353 



CHAPTER IV. 

STRUCTURAL DISEASES, OR DISEASES OF NUTRITION, ULTIMATE 
AND PROXIMATE ELEMENTS. 



SECTION I. 
NATURE AND CLASSIFICATION. 

522. Although we have had frequent occasion to advert to the 
changes in the process of textural nutrition effected bj inflammation, 
congestion, &c, and although nutrition might be included with pro- 
priety under the head of secretion (§ 178,) a primary element, it has 
yet been deemed better to defer all notice of the diseases of nutrition 
until now ; both because the preliminary consideration of disorders of 
the blood and of its vessels serves really as the best introduction to the 
subject, and because also structural disease cannot be resolved into ul- 
timate and proximate constituents. Analogy, indeed, might seem to 
indicate that ultimate structural disease is that which affects elemen- 
tary structures singly, such as muscular fibre, nervous matter, cellular 
texture, &c. ; but structural disorder is rarely found to be practically 
thus confined to one anatomical element : it rather involves all the tex- 
tures that are intimately associated together in the affected organ or 
part. 

Full details of the nature and variety of structural disease belong 
rather to the department of morbid anatomy than to the scope of this 
work. It will be sufficient if here the chief forms are alluded to while 
tracing the alterations in the function of nutrition which produce them. 
This method will enable us to class these diseases in an arrangement 
corresponding with that which was adopted with regard to the elements 
of functional disease (§ 104,) and will afford a facility for making a 
brief statement, under each head, of whatever is known regarding their 
nature and origin, and the remedies which influence them. 

As in the case of functional diseases, so of structural lesions, which 
are modifications of ordinary textural nutrition, they may be compre- 
hended under the three heads, increased, diminished, and perverted 
nutrition. 1 

1 Although considerable advances have been made in pathological anatomy, and 
although several new works upon the subject have appeared since the publication of the 
first edition of this treatise in 1843, it is satisfactory to me to find that the progress of 
knowledge has not in any material point superseded the views that were there given of 
the elements of structural disease, but that in many instances these views have been 
signally confirmed and extended. Under these circumstances, I have had to add to, 

23 



354 



STRUCTURAL DISEASES. 



ELEMENTS OF STRUCTURAL DISEASE. 



DISEASED 
NUTRITION 



(* Increased = hypertrophy. 
Diminished = atrophy. 



Perverted 



f Contraction 
j Dilatation 
altered j Obstruction 
mechanism j Compression 
| Displacement 
(^Rupture, &c. 



' Induration. 
Softening. 
Transformation and degeneration. 



r 



Euplastic 



Deposits ■{ Cacoplastic 



[_ Aplastic 



f Cicatrices. 
\ False membranes, 
f Cirrhosis, 
j Fibro-cartilage. 
1 Gray tubercle. 
[Atheroma, &c. 

{Yellow tubercle. 
Calcareous matter, 
&c. 



Morbid 
[ growths 



f Non- f^ sts - 

v , i Tumours, 
mahgnant | Hydatids> &c> 

( Carcinoma. 
Malignant \ Encephaloma. 
( Melanosis. 



The above classification is convenient on account of its simplicity, 
but it must be borne in mind that it is too precise to be rigidly appli- 
cable in the generality of cases. Different kinds of lesion of nutrition 
often graduate into each other, and are very commonly combined to- 
gether: hypertrophy of some textures co- exists with atrophy of others: 
perverted nutrition is mixed up with excessive or .defective nutrition; 
or several of these different changes occur in succession. Yv r e have 
already found this to be the case with the results of inflammation 
(§ 479 ;) and inasmuch as that process exaggerates and disorders the 
changes of nutrition, it has furnished us with many examples of the 
production of structural lesion. But the alterations that are now to 
come under consideration are such as take place altogether indepen- 
dently of distinct inflammation, and such as are mere modifications of 
the ordinary operations of nutrition or reparation continually going on 
in the textures of the living body. 1 

523. Continued nutrition of the organized textures is required for 
two reasons : — 1st, In order that their growth and development may 
be perfected. 2d, In order that the waste entailed by their vital 

rather than to modify the text; and in preference to new classifications and uncouth 
nomenclature, which it has been attempted to introduce from various foreign writers, I 
have retained my former division of the elements of structural disease,, designated by 
terms which are in common use among British pathologists. For further valuable infor- 
mation on details of morbid anatomy, however, I refer the reader to the works of Roki- 
tansky, Vogel, and Lehert; especially those of the first two authors, which have been 
ably translated and edited in English by Drs. Day, Swayne, Sieveking, and Mr. Moore : 
the useful manual of Drs. Handheld, Jones, and Sieveking, will also prove a valuable 
guide to the student. But I am acquainted with no work more rich in important patho- 
logical facts, enlightened by the advance of science, than the "Transactions of the Patho- 
logical Society of London," which under the able editorship of Dr. R. Quain have now 
reached their sixth volume. I shall have frequent occasion to refer to them. 

1 For an able summary of the present state of knowledge on the subject of nutrition, 
see Dr. Carpenter's "Human Physiology," 4th ed., p. 556. To it and to Mr. Paget's 
Lectures I am chiefly indebted for the matter of the following paragraphs, which have 
been compiled by my friend Dr. Mann. 



PROCESS OF NUTRITION. 



355 



activities may be repaired. But viewed in this light, the blood may 
be said to require nutrition as much as any of the solid structures of 
the frame. Its pale corpuscles must be nourished in order that they 
may be developed into red ones. And both pale and red must be 
nourished in order that they may elaborate fibrin, globulin, and hseina- 
tin, out of the more crude albuminous constituents. Analogy marks 
it as probable, in the highest degree, that the blood corpuscles are first 
formed in the lacteal glands by the multiplication and division of the 
little cells that so abundantly line the lacteal vessels, where they pass 
through these glandular masses. No chyle globules appear in the 
chyle until it has reached the mesenteric glands, but immediately af- 
terwards these globules present themselves. These globules, accord- 
ing to Mr. Paget's views, are slowly and gradually matured into the 
red corpuscles of the blood. So soon as the pale corpuscles are com- 
pleted they commence their vital operations by the formation of fibrin ; 
the chyle becomes coagulable as its globules are constituted. But in 
the ordinary course of affairs the pale globules develop into flattened 
corpuscles, cease to make fibrin, and form globulin and hsematin instead. 
It is an interesting fact that in young animals and in pregnant females 
the pale corpuscles are unusually numerous in the blood. During the 
early formation of textures a rapid cell-multiplication out of the sub- 
stance of the blood-plasma is necessary. Abundance of plastic fibrin 
for the extension and development of the mechanical parts of the frame 
is now required, and not of the richer globulin and hsematin, for the 
vigorous support of the nervo-muscular apparatus. In the textural nu- 
trition of adult animals, on the other hand, there is less call for rapid 
cell-formation, and less demand for fibrin, but there is more want of 
globulin and hsematin. Hence, cells then develop, in the main, more 
than they multiply ; — they have a longer individual duration, and main- 
tain the vital operations by drawing the requisite material out of the 
blood-liquor through themselves. The rapidity of the process of cell- 
reproduction diminishes with advancing age, or if augmented under 
such circumstances, this is on account of some morbid influence or state. 

But nutrition must be deemed, more or less, a vital process through- 
out. All germs can be artificially produced by the introduction of 
minute fat or oil globules into an albuminous liquid undergoing oxyda- 
tion (§ 211,) but the progressive development of these germs into per- 
fect cells, able to perform all the various functions of separating certain 
matters from the blood, maintaining their own integrity, and of repro- 
ducing themselves, only takes place when all the arrangements of the 
living organism are present in full perfection. It is then only that a the 
muscle and nerve cells appropriate the globulin and hsematin that is 
conveyed to them, converting it first into their own substance, and then 
degrading it into creatine, creatinine, inosite, fat, and other low prin- 
ciples, and getting their own force during the process of degradation. 
Cell -life is concerned in all the nutritive and constructive operations' of 
the frame. Not only do cells, the young and old corpuscles of the 
blood (pale and red,) perfect the nutrient principles of the highest and 
lowest textures of the body, the globulin, hsematin, and fibrin, as stated 
above ; but cells also then assimilate those perfected principles. The 



356 



STRUCTURAL DISEASES. 



gray vesicular masses of the nervous centres are composed of cells which 
undergo very rapid disintegration, and are no less rapidly reproduced. 
Nuclei are found abundantly scattered amidst the muscular fibrils, de- 
signed, no doubt, to be developed into the contractile cells of which 
those fibrils are composed. The simple fibrous textures (connecting 
tissue, ligament and membrane,) originate partly in fibrin and partly in 
cells, which are slowly converted into lengthened and condensed fibres 
by the fixation and further deposit of fibrin. Nucleated cells, or nuclei, 
with more or less fibrin, also constitute the basis of the other fabrics, 
which are more directly derived from the crude albuminous constituents 
of the blood, and are variously modified by growth and multiplication, 
and by the deposition of homogeneous or hyaline matter in their inter- 
stices. In some the cells are pressed together, and consolidated in rows 
and layers, as instanced in the epidermis, and in the epithelium of mu- 
cous membranes. In others the cells are enveloped in an amorphous 
or semi-organized fibrous substance of their own exudation, as in carti- 
lage ; or they become choked, and ultimately destroyed and replaced 
by earthy particles, which get arranged into the radiated and concen- 
tric laminse of bone. When all the laws and conditions that are con- 
cerned in the formations and operations of cell-life have been more 
carefully studied, and more fully ascertained, it is to be hoped that many 
of the mysteries of structural disease will have been fathomed at the 
same time, and made plain. Already this much, at least, is clear, that 
fault in any of the attributes of cell-life furnishes an element of mal- 
nutrition, and renders unfit for its office the material that ought to be 
fit to form part of a living structure. 

524. Since nutrition depends on the blood for its material, and on 
the supply of arterial blood for its activity, it may be anticipated that 
it must be modified by differences in the quantity and quality of the 
blood, and in its arterialization. It is in this way, when the onward 
development of the pale corpuscles into red ones is arrested, and fibrin 
is made out of substance that ought to be elaborated into globulin, 
hsematin, and nerve-matter, that the various structural changes of in- 
flammation are brought about. Diseases of nutrition are usually con- 
nected with diseases of the circulation and of the blood (§ 279 :) a mo- 
derately active circulation, and a rich state of circulating material, are 
favourable to healthy nutrition. Either too active or too feeble a 
movement, or poverty of blood, impedes it. Disordered quality or pro- 
portion of the several blood-constituents (§ 186, 211) renders it de- 
praved. These causes operate on the whole frame, and they commonly 
affect some parts' and textures more than others, because the nutritive 
operations are naturally more active in them, and are therefore more 
readily influenced. Thus fat and cellular texture are increased or di- 
minished more readily than muscle, muscle more readily than tendon 
or bone, &c; and for similar reasons degenerations and other structural 
changes affect some parts more than others (§ 311.) But structural 
diseases are commonly limited and local, on account of some peculiar 
conditions in the affected part, and of these none are more frequent 
than such as act through its circulation. It is hence that partial anse- 
mia, congestion, determination of blood, and inflammation, lead so 



HYPERTROPHY. 



357 



often to limited structural disease. A similar remark has been made 
in regard to diseased secretion (§ 159) and other elements of disease. 
If the nervous influence affects nutrition, it is probably through its 
operation on the circulation. Thus a paralyzed limb wastes because, 
not being exercised, it is not so freely supplied with blood. The mus- 
cles of the limb of a frog, the nerves of which are divided, lose their 
irritability and waste also ; but Dr. John Reid has shown that by ex- 
ercising these muscles by electricity, which promotes the circulation, 
both their irritability and nutrition are maintained. 



SECTION II. 
INCREASED NUTRITION — HYPERTROPHY. 

525. Hypertrophy, as a disease, is always partial ; for although the 
whole body in cases of obesity acquires an enormous bulk, this is due 
to the extraordinary growth of the adipose tissue alone, one of the nu- 
merous textures of the frame. When the nutrition of the various struc- 
tures has attained the highest point which health allows, there is no 
farther increase of size in them, and the superfluous nutriment conse- 
quently accumulates in the blood-vessels, causing plethora (§ 276.) 
Hypertrophy may affect individual textures, or ivhole organs composed 
of many textures : in the former case, it may be called simple hyper- 
trophy, and is an ultimate element of structural disease; and in the 
latter, complex hypertrophy, and is a proximate element. A few ex- 
amples of both kinds may be instructively cited. 

526. Muscles are enlarged by full exercise, alternated with a due 
amount of repose, a healthy and well-nourished condition of the blood 
being also present. Increased development of the voluntary muscles 
under such circumstances cannot be called disease ; but I have seen it 
produce inconvenience when occurring in the sternocleido-mastoid 
muscle, long the seat of convulsive motion, in consequence of giving 
too great power to the muscle, and so tending to perpetuate the dis- 
tortion. The best cure for this would probably have been Bieffenbach's 
operation of dividing the muscle, as employed in the case of squinting. 
Muscular hypertrophy is however chiefly productive of disorder when 
it affects involuntary muscles. Thus, when it occurs in the heart, in 
consequence of continued excitement in sthenic subjects, the violence 
with which the enlarged organ moves and propels the blood, produces 
bad consequences. The muscular fibres of the bladder become hyper- 
trophied when there is difficult micturition from enlarged prostate, or 
from any other cause : those of the stomach and intestines do the same 
in consequence of strictures in the further part of the canal ; those of 
the bronchi become so in spasmodic asthma. In these examples, (as 
in all others of true hypertrophy,) the increase takes place in the proper 
tissue, that is, in the muscular fibres : in what mode this happens, whe- 
ther by the new formation of cell-germs and by their subsequent elon- 
gation into fibres, or by the splitting and growth of the original fibres, 



358 



STRUCTURAL DISEASES. 



has not been accurately ascertained with respect to unstriped muscles ; 
but Harting has shown that striped muscles grow by the increased 
size of the fibres, and not by their multiplied number. 

527. Hypertrophy of the interstitial filamentous textures of the 
lungs, liver, and other secernent organs, occurs after long continued 
congestion caused by disease of the heart (§ 311.) When it affects 
the cellular texture of the lower extremities it appears to be a chief 
constituent of elephantiasis. Hypertrophy of the epidermis happens 
in callosities of the skin, and in corns, excited by continued irritation 
or pressure, which operates by causing determination of blood to the 
part. Another form of hypertrophy of the cuticle arises from chronic 
inflammation, and is instanced in psoriasis, chronic eczema, and impe- 
tigo. The cuticle is here retained, instead of being duly shed, and 
from its stiffness it often cracks into chaps or rhagades. In the more 
temporary and slight cutaneous flushes, congestions, or inflammations 
of erythema, scarlatina, lepra, and pityriasis, superfluous epidermis is 
thrown off in a peeling of the skin, or in detached scales. But ichthy- 
osis presents the most extraordinary example of this sort of hyper- 
trophy in excess ; in this disorder the dried epidermic cells accumulate 
in a solid state, so as to form scales, or coarse bristle-like projections. 
These affections of the epidermis have their parallels in diseases of 
mucous membranes ; but the surfaces of these membranes being bathed 
with liquid secretion, the nucleated cells, which stand in the place of 
those that on the skin form solid scales, are here thrown off with the 
mucus, and are presented in it as floating shoals of epithelium scales, 
together with mucous cells and a viscid amorphous fluid (§ 455.) Such 
disordered secretion of the mucous membranes not unfrequently co- 
exists with cutaneous diseases : thus, bronchial congestion with viscid 
expectoration commonly occurs in persons affected with psoriasis and 
lepra. 

528. Complex hypertrophy, or enlargement of organs of a healthy 
kind may result from a more copious flow of blood being determined 
to them, in consequence of their increased use. It is thus that the 
uterus becomes hypertrophied in pregnancy: the breasts during lacta- 
tion ; and that one kidney becomes enlarged when its fellow is inca- 
pacitated by disease. The brain is developed in proportion to the ex- 
ertion and activity of the mind; and when this is carried too far, if 
inflammation, congestion, or some other vascular disorder of its struc- 
ture, is not induced, the organ is apt to become hypertrophied, until 
its bulk is too great for its bony case, its vessels get compressed, and 
it becomes indurated, and, as an obvious consequence, its functions are 
more and more impaired. Thus, in young subjects who have been re- 
markable for precocity and activity of intellect, the brain becomes 
over-nourished and too large, and fatuity and coma ultimately result. 
Mucous and cutaneous follicles sometimes acquire an extraordinary 
development after continued excitement, or even without any such ob- 
vious cause. Bursse become enlarged in situations exposed to much 
pressure or friction, as, for instance, on the shoulders of porters, the 
knees of housemaids, the elbows of miners, and the ankles of tailors. 

The hypertrophy of the liver and spleen so common in protract- 



HYPERTROPHY OF ORGANS. 



359 



ed ague, may very fairly be referred to the frequent repetition and 
long continuance of the enormous congestions which the disease induces 
in those organs (§ 310.) I have known a similar enlargement in them 
to ensue after prolonged exposure to cold and wet. In some cases, 
however, where there is hypertrophy, no such external cause can be de- 
tected ; the enlargement then must be referred to some peculiar con- 
dition in the circulation of the affected organs, or to an unusual ac- 
tivity in the molecules that nourish them. To this obscure category 
belongs the enlargement of the thyroid gland which is known as bron- 
chocele. 

The fatty enlargement or hypertrophy of the liver, and of adipose 
texture in general, may in many cases be referred to the ingestion of 
a large quantity of fatty food, or to a defective performance of those 
functions by which fat is eliminated from the system (§ 224 ;) and in 
all respects the increase of this constituent must be viewed less as indi- 
cating a peculiar activity of nutrition, than as marking a predominance 
of its chemical material in the blood. 

529. The general treatment of hypertrophy should depend on the 
pathological cause which has induced it. In most cases, this is some 
variety of hyperemia, and the treatment suitable for the variety is to 
be employed, (see Congestion, Determination of blood, and Inflamma- 
tion.) But there are remedies which seem to be especially calculated 
to counteract the hypertrophy that is thus induced ; such are iodine 
and its preparations, mercury, alkalies and their salts, and, in the more 
sthenic cases, sedatives and evacuants, conjoined with low diet. The 
same remedies are occasionally useful also in hypertrophy that is less 
distinctly connected with hyperaemia, such as bronchocele. It is al- 
ways judicious practice to aim as much as possible at the removal of 
the exciting causes of the condition, as by tranquillizing the circula- 
tion in hypertrophy of the heart ; by soothing irritations of the sto- 
mach, bladder, and other organs, in obstructive diseases of these viscera ; 
and by changing the patient's residence in visceral enlargements con- 
nected with endemic influence. Hypertrophy of the heart calls for 
the use of judicious sedatives to moderate that excited action on which 
its undue nourishment depends ; but care must be taken that the action 
is not too much reduced ; otherwise its excitement is apt to be replaced 
by exhaustion, and hypertrophy by dilatation and degeneration. I 
have found much advantage from short courses of iodide of potassium 
with liquor potassae, or bicarbonate of potass and digitalis, followed 
by mild preparations of iron or other tonics. In many instances hy- 
pertrophy of the heart appears to be induced and kept up by the pre- 
sence of an irritating matter in the blood ; generally some excrementi- 
tious matter which ought to be thrown off by the kidneys. Hence the 
suitableness of the above named remedies, which distinctly exercise a 
diuretic eliminative influence. I am quite sure that simple hypertro- 
phy of the heart is sometimes removed under these and similar means. 



360 



DISEASES OF STRUCTURE. 



SECTION III. 
DIMINISHED NUTRITION — ATROPHY. 

530. Atrophy, unlike hypertrophy (§ 525,) may he a general dis- 
ease ; that is, all parts of the body may waste together, so much as to 
impair their functions. General atrophy, marasmus, or emaciation, 
consists in the removal of a considerable quantity of the textures of 
the frame by decay and absorption without an equivalent reparation 
by nutrition (§ 523.) The organic materials of the body are not per- 
sistent, but are, more or less, prone to decay, and become effete or 
worn out in a limited period of time : or, as Dr. Alison expresses the 
same fact, the vital affinities which hold their elements together, cease 
to be operative, and so they become subject to common chemical affi- 
nities which tend to the dissolution of their molecules; the oxygen con- 
veyed into the blood by respiration being a chief instrument in their 
decomposition. But in the healthy body there is a reparative process 
continually countervailing this decay, by the deposition of new ma- 
terials whose vital affinities are energetic, and therefore able to main- 
tain the integrity of the textures (§ 523.) Hence the causes of atrophy 
may be divided into circumstances which promote decay, and those 
which impair or prevent reparative nutrition. Among the former may 
be ranged various influences which exhaust generally, such as excessive 
and prolonged exertion, or excitement, want of sleep, extreme anxiety 
of mind, or continued suffering; under the prevalence of these, a person 
is familiarly said to be "worn to a shadow," without any more distinct 
disease taking place. On examining the urine in such cases, it will often 
be found to contain an excess of urea, resulting from the decay of the 
textures. The secretion also presents alkaline characters, and is un- 
usually prone to decomposition ; and the intestinal and cutaneous ex- 
cretions exhibit an uncommon foetor, arising from a similar tendency 
to putrescence. Fever of a low or hectic kind may be excited as a 
result of these changes, and be then mistaken for the cause of the 
wasting. In cases of marasmus induced by excessive secretions or 
drains from the body, there is often also evidence of accelerated decay; 
thus, diabetes mellitus reduces the frame not only by the perversion 
and removal of its nourishment (§ 255,) but also by promoting the 
decay of its textures, manifested in the increased amount of urea ex- 
creted. Fevers and various acute diseases attended with much excite- 
ment, exhaust the vitality of the textures, and promote their decay, in 
like manner, and they do this especially as the disease declines, when 
the emaciation becomes most obvious. 1 

1 My friend Dr. Hodgkin considers a suspension of textural nutrition to be a chief 
cause of the phenomena of fever, and has very ingeniously applied this notion to explain 
many of its symptoms. — Lectures on Morbid Anatomy of Serous and Mucous Membranes, 
vol. ii., p. 490. Rokitansky and other German pathologists think that typhoid fevers 
depend on the production in the body of an organic matter which has some resemblance 
to malignant formations. To this they apply the term typhus-material, and they point to 
the follicles of the intestines and the parenchyma of the lungs as the most common places 



PARTIAL ATROPHY. 



361 



There are several circumstances which may impair or prevent repa- 
rative nutrition, and these may be effective in any or all the stages of 
the nutritive process, from the reception of food into the system to its 
appropriation by and assimilation to the living textures. As examples 
in this series may be mentioned — 1. Defective quantity or innutritious 
quality of food (§ 58, et seq.;) 2. Disorder of some part or parts of 
the digestive apparatus, such as occurs in severe dyspepsia and diar- 
rhoea, which prevent the clue elaboration of the chyle ; 3. Diseased me- 
senteric glands, or tumours obstructing the thoracic duct, whereby the 
supply of chyle to the blood is intercepted ; 4. Perversion of the elabo- 
rating process through which chyle is converted into blood (§ 253,) as 
instanced in diabetes mellitus and chylosus ; 5. Defect in the formation 
of fibrin (§ 196,) hsematin, and globulin out of the more crude albu- 
minous constituents of the blood, so that instead of becoming plastic 
material for repairing the texture, they have a tendency either to pass 
rapidly into decomposition, as in malignant fevers (§ 257,) or to con- 
crete in a cacoplastic or aplastic form, as in tuberculous diseases ; 6. 
Excessive discharges of various animal fluids, such as blood, pus, serum, 
milk, semen, or mucus; and morbid growths, which monopolize the 
nourishment of the body, such as tumours of various kinds; particularly 
cancer; 7. Parasitical creatures, such as hydatids, worms, &c. 

531. A consideration of the above series of causes of emaciation will 
suffice to show how uncertain it must be, as a symptom, if it be taken 
alone ; but when traced to its source, it becomes a very important in- 
dication of the extent to which that cause operates on the living body. 
Emaciation rarely continues, or advances to an extreme degree, with- 
out structural changes which render the cause of the mischief perma- 
nent: hence extreme marasmus is generally connected with tuberculous 
disease, carcinoma, (especially of the stomach,) or some serious organic 
lesion. The chief exception to this is diabetes, the intractable persis- 
tence of which still remains involved in much obscurity. 1 

532. Partial atrophy, the reverse of partial hypertrophy (§ 528,) 
commonly arises from defective supply of blood to the part. Some- 
times the defective supply is a consequence of the disuse of the part: 
thus it is that the eye wastes in confirmed blindness ; that muscles and 
whole limbs become atrophied in paralysis and anchylosis ; that the 
testicle and the maiumse waste with age, &c. Frequently partial atro- 
phy in an organ succeeds the changes induced by inflammation or other 
structural disease : the matter effused swells some parts, and so com- 
presses others of the texture, and preventing a due supply of blood, 

of its deposition. Under the microscope, however, this matter exhibits no character 
that can distinguish it from had fibrin or cacoplastic lymph ; and in accordance with the 
view given in the text, I consider it to be such, and tending to involve in a process of 
sloughing the excretory follicles of the intestines in the attempt to be thrown off, or in- 
ducing a deposit in the lung which has various pernicious tendencies (§ 474.) 

1 Saccharine diabetes is not however always a continuous disorder; for in some cases 
the sugar will for awhile entirely disappear from the urine, and reappear without any 
very obvious cause. In some instances of this kind the urine becomes quite natural in 
the interval, but in others it retains a high specific gravity, due to the presence of some 
organic matter, which is neither sugar nor urea. In several cases not strictly diabetic I 
have known sugar to appear in the urine for a time: but as these are unattended with 
emaciation, they hardly belong to the present subject. 



362 



DISEASES OF STRUCTURE. 



causes a subsequent atrophy. This is especially the case when the pro- 
ducts of inflammation or congestion are cacoplastic, as in cirrhosis of 
the liver and granular disease of the kidney, and in the consolidation 
of the lung from pleuro-pneumonia : the deposits here tend mechani- 
cally to contract and compress the vascular structures, and so to de- 
prive the organ of its nourishment; it accordingly shrinks in size, or, 
in the case of the lungs, the texture may become thin and emphyse- 
matous. In chronic pneumonia and phthisis, also, many of the pul- 
monary blood-vessels become obliterated, and the parenchymatous tex- 
ture either wastes or farther degenerates, according to its condition. 
Atrophy of the heart and brain has sometimes been found to be con- 
nected with ossification and partial obstruction of the arteries supply- 
ing them. The dwindling of limbs in children, and the lameness in 
old persons dependent upon shrinking of the neck of the thigh-bone, 
appear to be induced in a similar way by impediments in the vessels 
supplying the parts. 

533. The treatment of general atrophy (§ 530) should be directed to 
remove or obviate the cause, where that is practicable, to supply pro- 
per and adequate nourishment, and to promote the healthy action of 
the digestive, assimilative, and circulatory functions. The means by 
which these indications can be fulfilled, are too varied to be introduced 
here in detail : it must suffice to mention the chief remedies and mea- 
sures that are influential in counteracting the several pathological 
causes of atrophy. 

Atrophy, from excessive or prolonged exertion, is best treated by 
increased rest and nourishment, adding to the latter, wine or other 
stimulants if exhaustion continues present (§ 84 ;) that from anxiety 
of mind, prolonged suffering, or sleeplessness, by various medicinal 
narcotics, change of air and scene, and such other measures as are cal- 
culated to soothe under the particular circumstances. The effect which 
opiates and other narcotics occasionally exert in diminishing the quan- 
tity of urea excreted in such cases, points out that these medicines 
tend to control decay, and their influence may sometimes be aided by 
mineral acids and tonics of various kinds. The same remedies are 
useful in diabetes mellitus, but the arrest of the marasmus may then, 
however, be furthered by withholding all articles of food which can be 
converted into sugar — that is, such as are of a farinaceous, amylaceous, 
saccharine, and gelatinous nature (§ 256.) I have generally found 
that the excessive discharge and the emaciation of diabetes are effec- 
tually controlled by the full observance of this rule, but not by its par- 
tial adoption, as recommended by Dr. Prout. 

The treatment which is best suited to counteract the circumstances 
that impair or prevent reparative nutrition (§ 530) has been already 
alluded to when speaking specially of the several diseases and causes 
of disease classed under seven heads, in paragraph 530, and it would 
therefore be superfluous to dwell long on the subject here. The use 
of food as nourishing as the stomach can digest, and of tonics, medi- 
cinal and hygienic, as bracing as the body can bear, with due regula- 
tion of the excretions, affords the best chance of arresting or retarding 
the emaciation ; but the utility of these proceedings depends a great deal 



INDURATION AND SOFTENING. 363 

on the judgment with which they are directed. The utility of fat in 
the process of nutrition has been several times spoken of (§ 66, 211, 
224 ;) in addition to a fair allowance of milk, butter and fat as articles 
of food, or instead of them, if they disagree, the cod liver oil, is a valu- 
able adjuvant. Cod liver oil is best suited to scrofulous cases, but I 
have seen proofs of its utility in various kinds of emaciation, especially 
in convalescence from fevers, and from prolonged and wasting attacks 
of rheumatism. 1 

534. As partial atrophy sometimes arises from defective circulation 
in a part, it may occasionally be remedied by the adoption of mea- 
sures that are calculated to promote the passage of blood through it. 
Muscles that have wasted under disuse are sometimes strengthened and 
made to increase by blisters, stimulant frictions, electricity and exer- 
cise. Atrophy following inflammation or congestion may often be ad- 
vantageously treated by the remedies that are appropriate to the re- 
sults of these conditions, and especially by iodine in combination with 
tonics, as the iodide of potassium with sarsapariila, iodide of iron, &c. 
In most cases of structural disease treatment can do little to remove 
partial atrophy already induced, but it may retard its increase by re- 
storing a more healthy state of circulation throughout the body. 



SECTION IY. 
PERVERTED NUTRITION. 

535. Under this head are comprehended all those changes of struc- 
tural nutrition that go beyond mere plus and minus influences upon 
the natural molecular constitution of textures; either the quality of 
the fabric is altered, or new tissues, growths, or deposits are formed in 
connexion with the normal texture. Partial hypertrophy and atrophy 
often co-exist as well ; and when they do so, the observations already 
made with regard to those elementary changes may be extended to 
these, but with new additions. 

INDURATION AND SOFTENING. 

536. Induration and softening have both been named as occasional 
results of inflammation ; softening being commonly connected with the 
increased secretion and absorption that occur in acute inflammation 

1 As there is some reason to believe that certain inorganic matters are concerned in 
aiding the process of nutrition, it may not be thought irrational to suggest their trial 
in obscure cases of general atrophy, although -we may be ignorant of the mode in which 
they operate. I would particularize lime, phosphoric acid, and fluoric acid. Lime, in 
form of lime water, has long been used as an adjunct to a nutritious diet, and it exists 
in considerable quantity in most kinds of spring water. Phosphoric acid has been already 
recommended as a medicine, and in a diluted form it may be made an agreeable beverage. 
An agricultural friend of mine has employed the fluoride of sodium as an aid to nutrition 
in some of the lower animals, and he thinks with good effect. I have sometimes seen a 
prescription of fluoric acid for a human patient : but with its power of attacking glass, it 
is not likely that it ever reached the stomach of the patient. If administered at all, it 
should be in the form of fluosilicic acid, which may be kept in glass vessels. 



364 



DISEASES OF STRUCTURE. 



(§ 427 ;) or during the licjuefactive process of suppuration (§ 461 ;) and 
induration being rather a sequel of the more chronic affection, which 
causes a continued overflow of solid plastic matter (§ 479.) Both these 
changes sometimes take place independently of complete inflamma- 
tion ; but they probably are in most cases connected with some of its 
elements. 

537. Induration may be caused by an increased deposit of solid 
matter in a structure, or by compression of that structure, or both con- 
ditions may combine. In some forms of insanity, the inner table of 
the skull acquires the hardness of ivory. In newly-born children, the 
skin occasionally acquires unusual hardness and rigidity, making their 
little bodies "skin bound." Glands and other soft compound organs 
sometimes become hard without inflammation. Probably, in all these 
cases, there is prolonged determination of blood to the parts, and hence 
an exaggeration of the nutritive function ; but the matter exuded is 
more hyaline (§ 523,) or simply granular (§ 452, 3,) rather than con- 
sisting of highly organized cell-germs or fibres ; hence the result is not 
simply hypertrophy or increased growth, but a more condensed and 
homogeneous texture. A somewhat similar change is produced in the 
lung by compression from liquid effusion or by a solid tumour, espe- 
cially when the organ itself is also inflamed, as it is in pleuro-pneu- 
monia, where the pressure restrains the full development of the exuda- 
tion corpuscles. The induration of cartilage, &c, by osseous deposit, 
is more properly transformation than simple induration. So too in- 
duration of the liver, kidneys, and other analogous organs, is generally 
accompanied by interstitial deposits, and other changes of structure. 

538. Softening arises from different causes in different textures. In 
some instances the cause, being peculiar to the structure, may be called 
specific. Thus in the bones the change proceeds from a substitu- 
tion of fat in place of phosphate of lime, the earthy matter which 13 
destined to give them solidity. 1 The softening of the stomach com- 
monly found after death results from the solvent action of the gastric 
juice. The softening of various textures, and especially of the mus- 
cles, in fevers and other cachectic states, is connected with a defect of 
fibrin and globulin in the blood (§ 196 :) the same cause which removes 
or prevents the formation of these plastic matters (§ 216,) apparently 
dissolves or loosens the more solid parts of textures. In several cases 
of cachectic disease in intemperate persons, where there was degene- 
ration of the liver and kidneys, I have found -after death a general 
softening of the solids, and an ; unusual abundance in them of oil glo- 
bules, readily detected by the microscope (§ 258.) In other instances, 
softening is a variety of atrophy arising from a defective supply of 
blood ; so that the texture of the part decays, and is absorbed away 
faster than it is repaired. Softening of the brain and heart is thu3 
sometimes found to be connected with fatty or calcareous degeneration, 
and partial obstruction of the arteries supplying those organs. 2 Soften- 

1 Dr. Garrod, Trans, of the Pathological Society of London. 1847-8. 

2 For examples, see Trans, of the Pathological Society of London, Drs. Quain and 
Sibson; vol. iii., p. 242 and 246. Dr. Kirkes, Med. Chir. Trans., vol. sxxv., p. 281. 
Mr. Shaw, Pathol. Trans., vol. iv., p. 29. 



INDURATION AND SOFTENING. 



3G5 



ing of the affected muscles occasionally accompanies paralysis, espe- 
cially when it is caused by the poisonous influence of lead. Partial 
softening, as well as atrophy, now and then follows inflammation, and 
is under such circumstances to be ascribed to the obstruction of the 
vessels which the affection has produced. In this way softening of 
portions of the brain is induced by meningitis; softening of the heart 
occurs after pericarditis ; softening of the stomach and intestines after 
some kinds of gastro-enteritis ; and softening of the articular cartilages 
after their inflammation. In general terms, therefore, softening may 
be described as a variety or degree of atrophy, characterized by more 
or less change of solid into fluid or semi-fluid matter. In most in- 
stances the fluid exhibits an abundance of fat globules, which establish 
the affinity of softening to fatty degeneration, to be noticed hereafter, 
as a result of degraded nutrition. 

Although in all cases of partial softening, the cause is chiefly local, 
yet a non-fibrinous or aplastic condition of the blood materially contri- 
butes to the result ; and it is a matter for serious consideration whether 
the continuance of antiphlogistic measures and abstinence may not oc- 
casionally promote this change. Some of the most distinct cases of 
softening of the heart and brain that I have met with, have occurred 
where the patients have been long kept in a reduced state for fear of 
a return of inflammation to these organs. 

539. Induration and softening being opposites of each other, al- 
though sometimes preceded by similar causes, require, to a certain ex- 
tent, parallel modes of treatment, but in an opposite way. Induration, 
consisting of condensed hypertrophy, and often arising from prolonged 
determination, may be best attacked by partial antiphlogistic measures, 
especially such as tend to remove obstructions and deposits (§ 511, 
515.) Thus mercury and iodine, externally and internally used, and 
alkaline saline medicines, seem to possess some power to disperse hard 
swellings; and setons, issues, or suppurating counter-irritants, which 
draw away blood and nutriment from the indurated part, are in some 
cases found to be serviceable. But extreme antiphlogistic or reducing 
measures are not advisable (§ 218,) inasmuch as induration itself im- 
plies already a degradation of the nutritive material (§ 537,) and does 
not result simply from acute or sthenic inflammation. 

540. In cases of softening that are not specific (§ 538,) the appro- 
priate indications of treatment are, to restore a more fibrinous or plas- 
tic state of the blood, and to improve the circulation in the atrophied 
part. In fevers and cachectic states, where the softening is general, 
the first should be the> principal aim, and some of the means of fulfil- 
ling this have been already noticed (§ 216.) Besides nourishing food, 
and the employment of agents which improve the digestion and circu- 
lation, tonics and stimulants are often of use. How far the operation 
of mineral acids, bark, and other similar tonics may depend directly on 
their astringent or bracing influence upon the animal fibre, it is not 
easy to determine ; but after fevers, and in cachectic states, these agents 
certainly do appear to improve the quality and firmness of the solids 
in some more immediate way than by merely exciting the circulation, 
and ameliorating the condition of the digestive organs. So, too, the 



366 



DISEASES OF STRUCTURE. 



operation of stimulants, both local and general, probably goes beyond 
that which is simply incident to accelerating the circulation, and de- 
termining blood to parts where it is ill supplied: it probably also in- 
creases the production of fibrin and corpuscles at the expense of albu- 
men, just as we see the same to result from the application of stimu- 
lants before they cause inflammation (§ 294, 415.) The relief some- 
times afforded to the symptoms of softening of the brain and heart, 
where all inflammation has ceased, by the administration of mild stimu- 
lants, tonics, and a moderately nourishing diet, is too little known to 
those who have always the dread of inflammation before their eyes, and 
who yet forget that a chief evil of inflammation is the injury it inflicts 
on the function and structure, which endures even when the inflamma- 
tion is gone or when it is but of trivial amount. The beneficial effect 
of nourishing diet and stimulant applications on soft, flabby ulcers is 
another argument in favour of the adoption of the same kind of treat- 
ment in cases of internal disease, where the general weakness, apyrexia, 
pallidity, and muscular emaciation preponderate greatly over the symp- 
toms of local irritation. The principal benefit arising from the use of 
stimulants and tonics maybe fairly traced to their promoting the healthy 
formation of blood, and to. their causing an increased vigour of cir- 
culation ; but there are some agents which seem to augment the plasti- 
city of the blood, withouf exerting any remarkable tonic influence. 
Such are nitric acid, nitromuriatic acid, and chlorate of potass, the 
powers of which to promote the healing of cachectic or spreading ul- 
cers are very decided ; I have also obtained much advantage by the 
employment of these medicines in various cachectic states, following 
prolonged acute disease, or habits of intemperance. It seems proba- 
ble that they act chiefly by supplying to the blood the oxygen neces- 
sary for the formation of fibrin (§ 211) or deutoxide of protein, or for 
other processes of vital elaboration; the respiration [in its weakened 
state being inadequate to furnish a due amount. The purest air, and 
such muscular exercise and superficial friction, as may tend to make 
the respiration and circulation more effective, are beneficial in these 
cachectic states on a similar principle. 

541. The treatment of the specific kind of softening which is apt to 
affect the bones is not yet satisfactory. The circumstances which pro- 
mote or impede the deposition of phosphate of lime in the osseous tex- 
ture, are not clearly made out; but measures of a tonic nature com- 
bined with appropriate nourishing diet, have been found to be deci- 
dedly useful in the rickets of children. The mollities ossium of adults 
is a yet more obscure affection, and comprising as it does so entire a 
perversion of the natural process of nutrition of bone, it is hardly to 
be wondered at that it should prove intractable. The constant pre- 
sence of fluoride of calcium and silica in bone suggests the possibility 
of their being concerned in promoting the deposition of the phosphate 
of lime ; the fluosilicic acid might therefore deserve a trial in this un- 
manageable disease. The formation of callus at the ends of fractured 
bone, and the completion of the ossific process in it, are without^doubt 
promoted by generous diet and tonics. 



DEGENERATION— FIBROUS. 



367 



SECTION V. 
TRANSFORMATION AND DEGENERATION OF TEXTURES. 

542. When one elementary texture is replaced by another, as, for 
instance, when muscle becomes simply fibrous structure, it is said to be 
transformed. The term degeneration is also commonly applicable to 
the change; because the substituted texture is mostly, as in the case 
alluded to above, lower in vital character than the one that is replaced. 
The chief exceptions to this are, the transformation of skin into mucous 
membrane, when by anchylosis of a joint an external surface is brought 
almost to the condition of an internal one ; and the transformation of 
mucous membrane into skin, when the uterus has been long prolapsed. 
In these instances, the changes appear to arise from the physical con- 
dition in which the texture is placed : the exudation corpuscles remain 
soft and moist, and become epithelium scales and mucous globules in 
one case, and they dry into epidermic layers in the other. It is not 
so much that one structure is transformed into the other, as that one 
rudimentary base is developed into different forms by the agency of 
the special circumstances to which it is exposed. 

Muscle is sometimes changed into simple fibrous or fibro-cellular tex- 
ture, after the inflammation of contiguous parts. Loss of muscular 
substance, in consequence of wounds or from ulceration, is generally 
replaced by a similar fibro-cellular texture, and never by new muscles. 

543. Animal textures are liable to various kinds of degeneration ; 
of these four may be particularly specified as having distinctive physical 
and chemical characters ; they are the fibrous, the granular, the fatty, 
and the osseous or calcareous. All present features of deterioration 
or degradation in the scale of organization, as is implied in the term 
degeneration ; and this degradation takes place in the order in which 
the four several forms are arranged above. In chemical composition, 
and in a fainter degree, in physical condition, the series analogically 
presents a successive descent from animal, through vegetable, to mi- 
neral composition. 

Fibrous degeneration chiefly affects muscular structures, and espe- 
cially occurs when inflammation has existed long in or near them. Thus 
parts of the muscular fibres of the heart have been found converted into 
a dense fibrous tissue after endocarditis and pericarditis; 1 the same 
thing has happened to the muscles of the limbs after prolonged fascial 
rheumatism ; and to the intercostal muscles and diaphragm in chronic 
pleurisy. Age ordinarily works a similar change, as is illustrated in 
the tough and sinewy condition and wasted size of the muscles of old 
animals (§ 48.) The fibrous tissue thus formed resembles that existing 
naturally in the tendinous and fibrous structures of the body; it con- 

1 I have notes of several cases in -which this fibrous degeneration had taken place in 
the interior of the heart. An example occurred in the case of a gentleman from India 
whom I saw "with Dr. James Bird, and a notice of the appearance may be found in the 
Trans, of the Patholog. Soc, vol. iii., p. 276. 



368 



DISEASES OF STRUCTURE. 



sists of closely knit bundles of fibres, which, however, have a scantier 
distribution of nuclei, and very few blood-vessels amongst them. The 
fibres are usually also coarser, and here and there present granular ir- 
regularities. They often exhibit a tendency after a time to degenerate 
into the yet lower forms of degraded substance; — the granular, the 
fatty, and the osseous. In chemical composition the fibres belong to 
the gelatigenous group of tissues. Several parenchymatous organs, 
particularly the spleen, the liver, the kidneys, and the lungs, are oc- 
casionally affected by a change which seems to amount to fibrous de- 
generation, a dense filamentous tissue pervading, and more or less su- 
perseding, their natural structures ; but as in all these instances there 
is a great increase in the density of the organ, it seems to be more 
correct to view the new fibrous material in the light of an interstitial 
deposit, rather than in that of a transformation of the proper textures. 
This will be again considered under another head. 

544. Granular degeneration is also frequently met with in various 
organs, and is, like the structural change just noticed, the result of a 
cacoplastic deposit in the interstices of a texture; but this exhibits a 
granular instead of a fibrous character. The same appearance is some- 
times induced under the deteriorating influence of mal-nutrition, chronic 
inflammation, and old age, when there is no augmentation of substance. 
It has been just now remarked that morbid fibrous tissues sometimes 
tend to this condition. But the same state of things may take place 
in the normal fibrous and elastic textures, especially those that form 
part of the vascular apparatus, impairing their cohesion and transpa- 
rency, and rendering them liable to undue extension, laceration, and 
rupture ; or constituting the first stage of a yet further degeneration 
into fatty or calcareous matter. Under the microscope the structure 
presents a remarkable increase of aggregated granules, and a corre- 
sponding diminution of the fibrous or filamentous element. The gra- 
nules are not highly refractive, and there are no free oil globules; in 
these respects the condition differs from fatty degeneration ; the mate- 
rial is neither so opaque nor so fragile as the true fatty atheroma. 
This form of degradation is probably intermediate between the fibrous 
and the fatty or osseous forms ; I have repeatedly observed it in the 
walls of an artery which presented both these kinds also. The chemi- 
cal composition of degraded granular structure is not certainly known ; 
but it is probable that it is either of a gelatinous or albuminous nature, 
and is mixed with molecular fat. Cacoplastic deposits and recent 
lymph sometimes degenerate in this mode. 

545. Fatty degeneration was long since described by Laennec as 
affecting the muscles, the liver, and some other structures. It is to be 
carefully distinguished from fatty accumulation, which is merely hy- 
pertrophy of the natural adipose tissue, and which may by its bulk 
press on textures, and cause them to waste. True fatty degeneration 
consists in the conversion of the proper tissue of the part into fat; 
thus in fatty degeneration of muscles, the fibres themselves become 
pale in patches or spots, and under the microscope exhibit fatty glo- 
bules or granules within the sarcolemma; as the change increases, the 



FATTY DEGENERATION. 



369 



colour and consistence of the muscle are impaired, and its power is 
proportionately weakened. This change has been found in the heart, 
and in the voluntary muscles, under circumstances somewhat analogous 
to those which promote the fibrous degeneration of the same textures ; 
but apparently it occurs in connexion with still weaker constitutional 
powers, and with other evidences of impaired circulation and marked 
mal-nutrition. In these cases, as well as in some others, the arteries 
exhibit the atheromatous patches that Mr. Gulliver has proved to con- 
sist of fatty matter, which appears to be partly formed at the expense 
of the middle coat, and to be partly deposited in granules and globules 
under the inner lining. 

To the preceding description, which appeared in the former edition 
of this work, some important additions may be made from researches 
since published; especially those of Dr. R. Quain (Med. Ohir. Trans. 9 
vol. xxxiii.,) whose essay gives a far more complete account of the sub- 
ject than any that had appeared previously. His observations have 
reference more especially to fatty degeneration of the heart, which he 
distinctly proves to be an intrinsic conversion of the muscular fibres 
into fat; and to be the result of imperfect nutrition, in some instances 
in consequence of more or less obstruction of the coronary arteries. 
Dr. Quain has shown that sudden death in connexion with diseased 
heart is especially due to this lesion. 

Mr. Paget has observed fatty degeneration in the arteries of the 
brain in cases of apoplexy and softening of the organ; the change 
being obvious under the microscope, even when there was no appear- 
ance of ordinary atheroma. Dr. R. Hall has recently noticed the 
same condition in the branches of the pulmonary artery in connexion 
with tuberculous disease of the lung (Brit, and For. Med. Qhir. Hev. 9 
Oct., 1855.) The fatty degeneration of a certain portion of the cornea 
and iris has been shown by Mr. E. Canton to constitute the areus or 
cireulus senilis, which is often an important visible sign of the tendency 
to this degenerative change in the system. I have found it present in 
about nine-tenths of the cases in which I had reason to infer the exist- 
ence of fatty degeneration of the heart. But the areus senilis is com- 
monly seen, as the term implies, in aged persons, and in those also who 
are prematurely old through much anxiety or mental labour, or through 
prolonged habits of dissipation. It has likewise been observed, as a 
sequel to protracted disease in the eye itself. Fatty degeneration has 
been found in several other organs, generally in connexion with other 
changes of structure, impairing the nutrition and function of their na- 
tural tissues; for example, in the liver, kidneys, pancreas, stomach, 
urinary bladder, and the placenta. But a similar conversion into fat 
appears also to attend certain processes of a salutary kind: thus, the 
removal of solid inflammatory deposits seems to be aided by their par- 
tial conversion into fat, 1 and Kilian and Rainey have distinctly shown 
that the muscular substance of the uterus is removed in this way after 
gestation. 2 

1 Paget's Lectures, Med. Gaz., vol. xlv. 

2 Trans, of Pathol. Soc. London, vol. iii., p. 396. 

24 



370 



DISEASES OF STRUCTURE. 



Fatty degeneration of the liver is characterized by the pale opaque 
appearance of the viscus, by its low specific gravity (so that it sometimes 
floats in water,) by its soft greasy consistence, and by its greasing 
paper when heated upon it. Mr. Bowman pointed out that the liver 
cells naturally contain a considerable quantity of oil globules; and he 
suggested that fatty degeneration might here depend on an increase 
of this normal constituent, to such an extent as to press on and to cause 
the atrophy of the other tissues. It has been surmised that this oil is 
the principal material out of which the bile is formed by the secreting 
cells ; that its great increase in phthisis is mainly due to the accumula- 
tion in the blood of hydrocarbon which the lungs ought to remove, but 
cannot, in consequence of their diseased state ; and that this accumu- 
lation is chiefly found in the liver because it is that organ's office to fit 
the effete hydrocarbons for removal through the pulmonary exhalants. 
But if this explanation were correct, fatty degeneration of the liver 
would occur more constantly in phthisis and other diseases of the lungs 
than it does. I have met with it chiefly in females in whom emacia- 
tion has proceeded with great rapidity ; and I should rather be inclined 
to ascribe it to the accumulation of fatty matter, which is taken into 
the blood in consequence of the rapid decay of the textures, and is con- 
veyed to the liver as the proper organ for its excretion. It is also most 
probable that the fatty matter which is formed in tubercle, during its 
process of maturation and softening, may be absorbed into the circu- 
lation, and may so contribute to this change in the liver. 

But fatty transformation occurs also in other organs and tissues so 
commonly as to show that it must arise from some chemical tendency 
in animal substances, independently of the function of any particular 
organ. Thus we have already (§ 223, 258, 538) alluded to instances 
in which fat globules are found in increased numbers in various organs 
of the body, without there being any marked development of the common 
adipose textures. This has been noticed to occur in the bodies of per- 
sons who have been habitually intemperate, especially in connexion 
with disease in the liver, with or without jaundice; but I have also met 
with a few such cases in cachectic subjects who have not been addicted 
to excesses, and in these the urine has usually been albuminous, and 
the kidneys have exhibited more or less of the degeneration first de- 
scribed by Dr. Bright. In these examples, all the viscera which I 
have examined have presented an unusual abundance of oil globules, 
with some degree of softening, and the opaque yellowish paleness, 
common to ill-nourished tissues; the liver, spleen, kidneys, and even 
the muscles wearing a dingy red, or yellowish brick hue, instead of 
their proper colours. The increase of oil globules in the epithelium- 
cells of the kidney has been noticed by many observers, 1 particularly 
by Dr. George Johnson, who at first considered it to be the primary 
pathological change in Bright's disease of the kidney, corresponding 
with fatty degeneration of the liver; he also ascribes the impaired 

1 The earliest observations of fatty degeneration in the kidneys, seminal tubes, and 
several other organs, were made by Mr. Gulliver. — Edin. Med. and Surg. Journal, July, 
1843. 



PATTY DEGENERATION- 



' — PARTS AFFECTED. 



371 



function and wasted structure of the organ to this accumulation of fat. 
But it is now generally admitted that although in many cases of Bright's 
disease there is a great increase of fat in the cortical structure of the 
kidney, yet in other instances this is not the case; the granular de- 
generation being rather dependent on the accumulation of fibrinous 
matter in the tubules and cortical substance, than on the presence of 
fat. 

In fact the same increase of fat globules which is noticed in these 
cases in the kidney is found in other textures, and is the result of a 
chemical change which tends to convert animal substances in general 
into fatty matter. A similar tendency is manifest in the products of 
inflammation and other deposits. Thus the opaque exudation cor- 
puscles found by Mr. Gulliver in great abundance in lungs affected 
with low inflammation (especially if chronic.) and with gangrene, were 
ascertained by Dr. Davy to consist chiefly of olein and margarin. The 
pus of old abscesses, mature and softened tubercle, fibrinous vegeta- 
tions on the valves of the heart, and the softened fibrin found in blood- 
vessels or on serous surfaces that have been long inflamed, also contain 
a very large proportion of fatty matter in a crystalline, granular, or 
liquid form. The following extract from Mr. Gulliver's notes to Hew- 
son's works bears on the same point. "In Dr. Benjamin Babington's 
observations, the specific gravity of the milk-like serum of the blood 
appeared to be so regularly reduced, as to lead him to believe that 
the oil exists at the expense of the albumen. There are some facts in 
favour of the idea that albumen may be converted into oil. The rapid 
disappearance of the matter of the curd of perfectly fresh salmon, with 
the subsequent more oily state of this fish, may be owing to a conver- 
sion of this kind, according to the conjecture of Sir Humphry Davy, 
as I have learnt from Dr. Davy. I have observed that the oil of the 
liver of several fishes increases after death, probably in connexion 
with incipient putrefaction ; and Dr. Davy informs me that in the liver 
of the cod, after it had been kept in a damp place for twenty-five days, 
he found a small increase of oil, with the formation of carbonic acid 
and ammonia at the same time." — (P. 86, note.) 

But there is no chemical fact, which throws so much light on fatty 
degeneration, as that of the formation of adipocire from animal flesh 
when kept moist without access of air. I directed attention to this 
analogy in the first edition of this work ; Dr. Alison soon after, in his 
essay on "Vital Affinities," (Trans, of Royal Soc. of Edin. 1847,) pro- 
posed a formula by which the conversion of albumen and water into 
fat and carbonate of ammonia, may be readily explained. 

The chemical view of the nature of fatty degenerations thus advo- 
cated in the former editions of this work has now been completely 
established by the observations of Dr. B. Quain. He has produced the 
fatty conversion in healthy muscle by simply keeping it for a sufficient 
length of time in water to which a little nitric acid or spirit had been 
added to prevent putrefaction. After some days, oil globules appear 
in the fibres of the muscle, and gradually increase until much of the 
sarcous element is converted into them; and under the microscope, or 



372 



DISEASES 01 STRUCTURE. 



to the action of chemical tests, the change is proved to be identical 
with fatty degeneration as it occurs in the living body. 1 

The circumstances under which fatty degeneration mostly takes place, 
greatly favour the view that has been propounded above, of its being the 
result of chemical affinity. As a general disorder, or affecting many 
organs at once, it occurs in connexion with a feeble circulation and 
with low respiratory powers ; and it is promoted by conditions which 
increase the quantity of hydro-carbon of the blood, whether these be 
dependent upon habitual indulgence in alcoholic stimulants and the 
like ; or upon the imperfect removal of biliary matter from the system. 
An increase of fat, and especially of cholesterin, has been observed in 
the blood of aged persons. Fatty degeneration affecting a particular 
organ (except in the peculiar case of the liver,) is commonly the result 
of previous disease having impaired the freedom of the circulation 
through it, and often of its having left a granular or other cacoplastic 
deposit in its interstices, which not becoming fully organized, nor re- 
ceiving the renovating and oxidating influence of the circulating blood, 
gradually passes into the condition of fat, the lowest principle in the 
scale of animal compounds, and one that approaches to the nature of 
the simpler vegetable matters in the entire absence of azote. The same 
change may ensue more gradually from the failing circulation and re- 
spiration which attains in advancing age (§ 48;) and it will be accele- 
rated in any texture or organ whose structure has been injured by pre- 
vious disease, accident, or disuse. 

Under whatever circumstances the fatty transformation occurs, it is 
obviously a process of degeneration, or degradation to a very low scale 
of animal life ; its occurrence in gangrene is a striking illustration of 
this fact ; the vital properties of the organs which it invades become 
lowered, and the mechanical qualities also are greatly impaired. Thus 
muscles, so degenerated, lose much of their contractile power, and if 
subjected to distention, as they are in the heart, become dilated, and 
may be even ruptured. The tonic and elastic fibres of arteries also 
suffer in their elasticity, and yield in pouches, or become lacerated, or 
in process of time petrified. Glands and secreting structures lose much 
of their secernent activity, and their cells, vessels, and ducts get to be 
clogged and deranged in their functions by their fatty contents, espe- 
cially when these assume the solid form. Parenchymata and inter- 
stitial tissues suffer from the same cause in their properties of softness 
and' cohesion, and in the freedom of their circulation, and also become 
liable to the further changes of disintegration, and to calcareous deposi- 
tion, which is the last kind of degeneration to be noticed. 

546. Calcareous or osseous degeneration approximates the structure 
which it invades to the character of a mineral, and hence might not 
inaptly be designated by the term petrifaction. The tissues that are 
most liable to the change are such as are low in the scale of organiza- 

1 Dr. Hodgkin and I had previously observed instances of a decided increase of fatty 
matter in morbid specimens after death; and I had requested my clinical assistant, Mr. 
Edvrard Palmer, to make experiments on the subject, by keeping portions of organs in a 
moist state excluded from the air. as I expected a change analogous to that of adipocire 
Trould be found in them. 



CALCAREOUS DEGENERATION. 



373 



tion, and yet constantly moistened by blood-liquor, as for instance the 
cartilage, fibro-cartilage, fibrous tissue, and similar structures that are 
the results of disease. Morbid ossification has been commonly com- 
pared to the natural process by which bone is formed; but it resembles 
that process little more than in the deposition of solid phosphate of 
lime in the interstices of the tissue: where the tissue itself approaches 
to the nature of bone, the result may present a near approximation to 
true osseous structure, as is the case with ossified cartilage : but when 
it is the cardiac valves that are affected, the calcareous matter forms 
plates and masses which have only a remote affinity to the structure of 
bone. 1 In fact the most complete specimens of petrifaction gradually 
supervene upon the deposit of aplastic fibrin in lymphatic glands, in 
the lungs, on the surface of serous membranes, and on and under the 
lining membrane of arteries ; if these deposits escape fatty degenera- 
tion and softening, they are very apt to be ultimately converted into 
masses or plates of calculous or stony matter, in which there may be 
little or no animal substance. This process is therefore to be viewed 
as almost entirely of a chemical nature, and as consisting in the con- 
cretion and accumulation of calcareous salts, phosphate and carbonate 
of lime, in the debris of animal matter. It is uncertain whether this 
calcareous matter is the insoluble residue of successive acts of deposi- 
tion and absorption ; or whether it is the result of degenerating albumen 
exerting a chemical attraction over the phosphate of lime in adjoining 
fluids ; but the latter seems the more probable notion, and it is indeed 
strengthened by the fact that a similar petrifaction sometimes occurs 
in loose cartilages in joints, and in detached concretions in veins, (phle- 
bolites.) Andral and Dr. Carswell are of opinion that these concre- 
tions are produced by the gradual ossification of little clots of blood, 
which are first consolidated and then ossified. 

The petrifactive process is essentially a slow one ; and, as a sponta- 
neous change, occurs most in advanced age ; but, like other forms of 
degeneration, it may be induced and accelerated by inflammation, espe- 
cially when it is of a chronic kind. Thus the cartilages of the ribs, 
and of the air- tubes, and the walls of the arteries, are generally more 
or less ossified in old people : the same changes are also very apt to 
occur in earlier life, in consequence of repeated or prolonged attacks 
of inflammation in adjoining parts. 

It is scarcely necessary to point out the various modes in which mor- 
bid ossification tends to injure the structure and function : it renders 
the textures that it attacks rigid, inflexible, inextensible, inelastic, and 
therefore brittle and obstructive. It is this degeneration in particu- 
lar which stiffens the gait, shortens the breath, and weakens the circu- 
lation in advanced age (§ 48,) and which makes the frame unfit to bear 
shocks or sudden changes, that it is capable of resisting when pos- 
sessed of the pliancy, elasticity, and varying powers of earlier life. And 
so the same change induced by disease in a particular apparatus, such 
as that of the respiration or circulation, reduces that apparatus to the 

1 Dr. Hyde Salter lias traced in the structure of some of these osseous deposits a re- 
semblance to that of dentine. Trans, of Pathol. Society, vol. v., p. 35 : see also vol. vi. . 
p. 300. 



374 



DISEASES OF STRTJCTUEE. 



limited capacity of decrepitude: thus a young or middle-aged person 
with asthmatic breath or crippled circulation, is to this extent prema- 
turely old, and indeed encounters more suffering and danger in pro- 
portion as his other functions and feelings are active and impressible, 
and tempt him to efforts which the straitened organs are unable to bear. 
It is on this account that occasional attacks of spasmodic asthma and 
pulmonary congestion are very apt to occur in connexion with ossified 
bronchial tubes; and that painful and dangerous paroxysms of angina 
often supervene when the arteries and valves of the heart are in the 
same condition : whilst the more completely or uniformly petrified old 
man remains comparatively free from similar affections so long as he 
is kept in a state of vegetable or almost mineral quiescence. These 
considerations suggest important points of practical application. 

Treatment of Degenerations* 

547. It may readily be inferred from the preceding remarks, that 
if there are any measures which are capable of resisting the progress 
of degeneration of structures, they are such as tend to sustain the vi- 
tality of the frame, and to preserve the organic functions in equally 
balanced activity. Hygienic influences, such as pure air, regular ex- 
ercise, friction of the surface, baths warm or cold, as the system can 
best bear them, and nutritious and carefully selected food (§ 60, 219,) 
deserve the first mention. Of medicinal agents, those generally de- 
nominated tonics, may be of some little utility, such as preparations of 
iron, bark, arsenic and the mineral acids ; but, as in most cachectic states, 
the secretions are commonly more or less defective, these medicines are 
not well borne unless they are combined with others, such as altera- 
tive aperients and salines, which possess the power of obviating the 
deficiency; the combination is presented in a convenient and attractive 
form, in the various chalybeate and saline mineral waters of the most 
frequented spas. These are the favourite resorts of persons of "worn 
out constitutions," who are in truth more or less subjects of degenera- 
tive structural changes, and who find in the regular routine, and healthier 
habits, as well as in the remedial virtues of the waters and baths of 
these places, a degree of relief and a restoration of strength which 
they fail to obtain from medicinal treatment at home. 

Partial degenerations are promoted, as we have seen, by a disordered 
state of the circulation of the part, commonly from congestion or in- 
flammation in a low form ; hence the treatment should comprise the 
attempt to remove or counteract such local derangement by the em- 
ployment of gentle means, chiefly topical, that cannot compromise the 
constitutional powers of the patient. There are individual remedies 
which claim to be especially applicable to particular kinds of dege- 
neration. 

Fibrous and granular degenerations, as they are commonly partial, 
and result from continued or repeated inflammations, may be in some 
measure retarded by the less weakening forms of antiphlogistic reme- 
dies, as for instance the employment of counter-irritation, local 
bathing, and friction with stimulant liniments, and the external and 
internal use of preparations of iodine, and the alkalies. These means 



DEGENERATIONS — TREATMENT. 



375 



are serviceable in restoring power to muscles injured by rlieumatic and 
other kinds of inflammation, which tend to fibrous degeneration. Mer- 
cury is generally too weakening to be administered as an internal re- 
medy, but it is sometimes useful when applied externally. 

The peculiar chemical nature of fat, and its special relation to 
particular organs, the lungs and the liver, suggest to us means which 
may tend to prevent its accumulation in the system, and its substitu- 
tion for the more highly animalized textures. The rigid exclusion of 
all fatty articles of diet, the moderated use of saccharine matter and 
fermented liquors, and the adoption of lean meats, bread, and succu- 
lent vegetables for food, conjoined with a due portion of salt and other 
condiments ; the promotion of free circulation and respiration, by re- 
gular exercise in pure air; occasional bathing and friction to promote 
the action of the skin ; and the regulation of the bowels, aided, if ne- 
cessary, by medicines which augment the secretion of bile; such are 
the chief means by which the adipose cachexia is to be combated. The 
tonic remedies recommended in degenerations in general, are also unques- 
tionably of service here, particularly the various preparations of iron 
and quinine; and I have known several examples of temporary benefit 
resulting from their employment in cases which ultimately proved to 
include fatty degeneration of the heart. In some instances the nitric 
or nitromuriatic acid has been found advantageous; in others, ammo- 
nia ; and one is tempted to attach some meaning to the peculiar com- 
position of these agents — as being of an opposite nature to fat — the 
acids affording abundance of oxygen which may remove a part of the 
superfluous fat, and both these and ammonia supplying azote which 
may contribute to the formation of a more highly animalized plasma. 
The disposition which fatty material has, to assume the solid forms in 
these degenerations, suggest that an advantage is likely to arise from 
the use of some solvent capable of liquefying the adipose concretions ; 
and I know of no agent so likely to possess this quality as the liquid 
part of cod-liver oil, the power of which to remove deposits that abound 
in fat will shortly again come under notice. 

Very little is known of any measures that are calculated to coun- 
teract the calcareous degeneration, further than such as have been 
already recommended with the general object of sustaining vital 
energies, and preventing the nutrition of parts from being perverted by 
inflammatory or congestive disorder. Hydrochloric acid exerts a re- 
markable solvent power on salts of lime : in some cases mollities ossi- 
um has been supposed to have arisen from an excessive use of salt, but 
it is quite uncertain whether such a property would reach to the mor- 
bid deposition of phosphate of lime in textures. Some hints have been 
thrown out before, regarding the expediency of limiting the subjects of 
ossification to a restricted sphere of excitement and exertion (§ 546.) 



376 



DISEASES OP STRUCTURE. 



SECTION VI. 
DEPOSITS IN OR UPON TEXTURES. 

5-18. The term deposits is applied in a pathological sense, to mat- 
ters which result from an overflow of nutritive material beyond the 
amount that is necessary for the nutrition of the textures. The struc- 
tural lesions hitherto considered are alterations of the textures them- 
selves ; deposits are new matters added to the textures. The basis of 
all morbid deposits is the fibrinous matter of the blood; in speaking of 
the products of inflammation (§ 450 — 3,) we have described their va- 
rieties in relation to their plasticity or capability of organization. The 
same relation intimately affects the character of deposits, which take 
place independently of inflammation, as results of overflow and perver- 
sion of the material of reparative nutrition, which so may be either 
euplastic, cacoplastic, or aplastic. What has been said of these pecu- 
liarities of perverted nutrition when treating of inflammation, has an- 
ticipated the necessity of alluding to them in detail now, and it will 
therefore suffice to advert to the circumstances in which they arise in- 
dependently of inflammation. 

Euplastic Deposits — Cicatrices. 1 

549. When a living part is wounded or injured, the breach may be 
repaired in four different ways: — 1. By the "immediate union" of 
Dr. Macartney. 2. By the "union of adhesion" of Hunter, which is 
the same with the "healing by the first intention." 3. By the "de- 
velopment of new tissue" from nucleated plasma; and 4. By "suppu- 
rative granulation." It was once a general opinion amongst patholo- 
gists, that inflammation is essential to the accomplishment of repair ; 
but it is now known that the first three processes enumerated above 
are completed without the occurrence of inflammation, and that, indeed, 
they are interfered with and arrested when it supervenes. The fourth 
process, that by suppurative granulation, is intimately connected with 
inflammatory action, and therefore its consideration does not belong to 
this part of our subject, although incidental allusion to it cannot be 
avoided. The connexion of inflammation with healing operations seems 
to have been mainly designed for increasing the plasticity of the blood 
in such cases as are deficient in this quality, and in which, therefore, 
the simpler means would fail. 

Considerable light has been thrown upon the nature of the reparative 
process by Mr. Paget, 2 and a very lucid and interesting resume of his 
views is given by Dr. Carpenter. 3 A considerable portion of the fol- 
lowing explanations is derived from these sources. 

The first method of healing, that by immediate union, is the simplest 
and most desirable of all. To Dr. Macartney the merit is due of first 

1 The following paragraphs have "been written by Dr. Mann. 

2 See Lectures on Nutrition, Med. Gaz., 1849. 

3 See Principles of Human Physiology, 4th ed., p. 572, and 3d ed., p. 613. 



DEPOSITS — EUPLASTIC — CICATRICES. 



377 



pointing out how little inflammation lias to do with this and analogous 
operations, and that in general the reparative powers are in inverse 
proportion to the tendency to, or presence of, inflammatory action. 
Immediate union mostly takes place in slight cuts, like those which 
are made in venesection, and in larger wounds under circumstances 
which prevent irritation or inflammation. There is no increased red- 
ness or swelling, and no obvious effusion of lymph. Parts that are 
placed in close contact, and without any intervening substance, simply 
grow together. As Dr. Macartney remarks, and as might he antici- 
pated, " this process is the slowest of all, but this is of little conse- 
quence when it is remembered that it is unattended with pain or con- 
stitutional disturbance, and that it leaves behind the best description 
of cicatrix." 1 This was the method of union which John Hunter 
spoke of as being "by the first intention." He believed that it took 
place through the medium of blood intervening between the lips of the 
wound, and becoming subsequently organized into a living bond. But 
it is now well known that this kind of union only takes place when no 
blood remains between the opposite sides of the wound. 

550. The "union by adhesion" of Hunter, (union by first intention 
of modern British surgeons,) commonly takes place in incised wounds, 
whose sides cannot be brought into perfect coaptation. The connexion 
is here established by the effusion of lymph into the vacant space, and 
by its ultimate organization through vessels passing into its substance 
from both surfaces ; this bond becomes an enduring cicatrix that is 
quite unlike the surrounding tissue. The mere fact of the effusion of 
plastic lymph to this slight extent is not deemed to indicate the presence 
of inflammation. 2 Whenever inflammation is accidentally set up, the 
bond fails to perform its task. 3 The only circumstance, under which the 
supervention of inflammation can be regarded as salutary, is when there 
is a deficient organizability in the lymph, in consequence of want of 
fibrin in the blood. It has been seen (§ 438) that inflammation aug- 
ments the quantity of fibrin in the circulating fluid, and every surgeon 
knows that there are cases of general depression, in which wounds with 
pale flabby edges will not heal until a certain degree of inflammation 
has been induced. 

1 Dr. Macartney's Treatise on Inflammation, p. 178. 

2 The following observation made by myself long ago illustrates this process: — I made 
a small pin-hole in the web of a frog's foot ; the capillaries that were divided yielded no 
blood, and became obstructed; but the circulation continued, although sluggishly, in 
those adjoining, which were distant from the puncture the length of sis or eight blood- 
discs. The next day, these vessels were no nearer; but the circulation through them 
was more active, and the hole was partly filled up. On the third day it was completely 
so, yet no moving blood could be seen nearer to the spot. On the fifth day the distri- 
bution of visible vessels was not altered, but the matter with which the hole was filled 
had contracted and become opaque, so that the adjoining vessels were drawn nearer to- 
gether; the opacity prevented my seeing whether any passed through the cicatrix." — 
Gulstonian Lectures, Med. Gaz., July 30, 1841, p. 721. 

3 Although I admit that inflammation in its pronounced form is not essential to this 
mode of reparation, yet there seems to be a close approximation to it in the process. 
When a frog's web is cut or pricked, the vessels adjoining the wound are immediately 
obstructed by coagulated blood; but in a few seconds, those just beyond become enlarged, 
and receive an increased current, and it is this determination of blood toward vessels 
which are obstructed, which causes an increased transudation of the plasma of the blood 
($419.) If this do not amount to inflammation, it differs from it only in degree. 



378 DISEASES OF STRUCTURE. 

551. The third process of repair takes place when wounds are too 
extensive to be healed either by "immediate union," or by a thin in- 
sinuated "layer of coagulable lymph." A mass of nucleated plasma is 
first formed, and then new tissues are developed out of this. But, as 
Mr. Paget has shown, the "filling up" takes place very differently ac- 
cordingly as the part is excluded from air, or exposed to it. In the 
first case the nucleated plasma is developed into fibrous texture almost 
without inflammation, and without constitutional irritation. In the 
second case it is developed into cells, of which those on the directly 
exposed surface degenerate into pus globules, and are cast off. Local 
inflammation then occurs to a considerable extent, and gives rise to 
constitutional disturbance, and a very serious drain upon the system 
is set up. It is a curious fact, that in cold-blooded animals the first 
bland form of this mode of healing is accomplished, even although the 
injured part is exposed to the air. Dr. Macartney has termed this 
proceeding the "modelling process," but it is really granulation effected 
under the most favourable conditions. Nature attempts to carry out 
this plan whenever an injury has been too extensive to admit of its 
being repaired by the "immediate" or the "adhesive" union. She 
does so by forming a scab, and so converting an exposed into a covered 
surface, whereby the irritating presence of the air is excluded, and the 
healing consequently effected without inflammation or irritation, as it 
could not otherwise be. 

552. When an open wound is healed by "suppurative granulation," 
the exposed surface is first "glazed" over by a layer of coagulated 
fibrin and colourless corpuscles. A period of complete inaction then 
follows, which may last from one day to ten, in which there is only a 
slight oozing of serous fluid; this is what Mr. Paget calls the "brood- 
ing time," in which either good or evil is hatching. The commence- 
ment of reparative operations is marked by the restoration of the flow 
of blood to the injured part. The current is slower, but fuller than 
usual ; more blood on the whole is thrown through the vessels, and 
plastic material is effused from them in consequence; this material is 
first formed in cells, but those in the deeper parts are developed into 
fibres, out of which the substance of the granulations is composed. But 
those on the surface degenerate into pus globules. The pus constitutes 
a sort of epithelial layer which protects the fibrous granulation mass 
beneath. In this new blood-vessels are formed by outgrowth from the 
neighbouring capillaries, which have become very large, and often even 
varicose. "The vessel first presents a slight dilatation in one, and 
coincidently in another point ; as if its wail yielded a little near the 
edge or surface. The slight pouches thus formed gradually extend as 
fluid canals or diverticula from the original vessel, still directing their 
course towards the edge or surface of the new material, and are crowded 
with corpuscles which are pushed into them from the main stream. 
Still extending they converge; they meet; the partition wall that is at 
first formed by the meeting of their closed ends clears away, and a 
perfect arched tube is formed, through which the blood, diverging from 
the main or former stream, and there rejoining it, may be continuously 



DEPOSITS — EUPLASTIC — HEALING PROCESS. 



379 



propelled." 1 Sometimes the projecting pouch gives way soon after it 
has originated, and blood corpuscles escape into the organizing plasma. 
At first they lie clustered confusedly together, hut soon they are ga- 
thered into the direction in which the new vessel should have been 
formed, and so "channel" out a way into the opposite capillary pouch. 
This variation of the process bears out Mr. Travers's remark, that the 
new capillary arch formed by outgrowth does not directly carry a 
stream of blood. Isolated corpuscles enter it, and oscillate backwards 
and forwards in it for some hours before any of them pass through it, 
so that the new channel cannot be regarded as only burrowed out by 
a file of corpuscles pushed in from behind, as some have maintained. 2 
Suppurative granulation differs from the granulation of closed wounds 
(the modelling process of Dr. Macartney,) chiefly in the fact that a 
large number of the exudation corpuscles deposited, degenerate into 
pus globules in the one case, and that none of them are thus wasted in 
the other. But in the former case, the presence of inflammation causes 
an increased quantity of fibrin to be formed, so that abundant granu- 
lations are made, and the solution of continuity is filled up much more 
rapidly than when the same repair is effected by means of more per- 
fectly developed structures in the absence of inflammation. Rapidly 
formed granulative substance almost entirely disappears, subsequently 
to the complete closing of the wound. Two opposite surfaces of firm 
granulation will sometimes grow together, if kept in contact with slight 
pressure. There are thus, then, two principal forms which materials 
effused to constitute new texture may assume: namely, the fibrinous 
and the corpuscular. In the former, the deposit resembles the firm 
coagulum of healthy blood, only that it is somewhat more distinctly 
fibrillated. In the latter, it is characterized by the absence of perfect 
coagulation, and the clot is replaced by an aggregation of cells re- 
sembling the corpuscles of the absorbent vessels and of the blood. The 
two forms are generally more or less mingled together, but in propor- 
tion as the fibrin predominates, the exudation substance is firm and 
plastic and organizable, and as the corpuscles are more abundant it 
tends to degeneration (cacoplastic or aplastic.) Inflammation makes 
the one form still more adhesive, and the other it pushes into suppu- 
ration. 

Under some circumstances the coagulated fibrin of the blood itself 
has been found to become vascular, and more or less organized. Clots 
of blood independently deposited in the blood-vessels have been rendered 
vascular, and coagula effused in the brain in apoplexy have been found 
penetrated by vessels. The colouring material of the blood does not, 
however, seem in any way to assist the process. Blood coagulated in 
or upon a wound falls off in a scab as soon as the wound is healed. 
Dr. W. T. Gairdner has lately made some observations that counte- 

1 Paget's Lectures in Med. Gaz., July, 1849, p. 72. 

2 There is nothing in Mr. Travers's observations -which controverts the inference, which 
is drawn from numerous other facts, that the motion of the corpuscles in these new 
channels is derived from the adjoining capillary vessels. The oscillatory movements are 
those of the pulsation of the heart, and are seen in many instances on the arterial side of 
obstructed capillaries. No current of blood, or file of red corpuscles can pass, until there 
is also a communication with the veins. — See note, p. 275. 



380 DISEASES OF STRUCTURE. 

nance the notion long since held, that blood and blood-vessels may be 
quite independently formed in effused substance, without any outgrowth 
from neighbouring capillaries. He adduces one case in which a false 
membrane had been made by the organization of a clot of blood, ef- 
fused into the arachnoid cavity in consequence of an injury. It exhi- 
bited a large varicose blood-channel without any very definite wall, 
and smaller branching vessels with distinct parietes, and there were 
in the large channel blood corpuscles of all dimensions, the smaller 
being far more abundant than in ordinary blood. The appearance was 
that which a rudimentary forming vessel and young blood would have 
presented, and there was no organic communication with neighbouring 
parts. 1 Dr. Quain exhibited at the Pathological Society specimens of 
loose fibrin passed from the urethra, in which there were ramified chan- 
nels closely resembling a network of blood-vessels. 2 

553. Remedial measures. — There are certain influences by which 
the performance of the euplastic process may be aided; but these vary 
according to circumstances. In some states the object is to cause in- 
creased determination of blood to the injured parts, and to augment 
the plasticity of the circulating fluid, so as to ensure a sufficient effu- 
sion of organizable lymph for the work to be done. More often the 
great aim should be to prevent inflammation. All treatment should be 
directed to secure, if possible, the "immediate" or "adhesive" union, 
in preference to any other mode of repair, or if this cannot be effected, 
to induce the "modelling process," rather than suppurative granula- 
tion. In the case of large burns on the bodies of children, the one or 
the other of these being pursued by nature, often determines the al- 
ternative of life or death. There are three principal things to be done 
in attempting to prevent the supervention of the suppurative in the 
place of the non-inflammatory method of repair. These comprise — 1, 
the exclusion of air ; 2, the regulation of temperature ; 3, the constant 
application of moisture. Dr. Macartney maintains that no other agent 
is so effectual as steam, first at high temperatures, and subsequently 
not so hot. Water dressing commonly answers exceedingly well in 
preventing inflammation. Iz operates by producing such a degree of 
cold as can diminish sensibility and vascular action, — and as Dr. 
Macartney thinks, can approximate the condition to that which is al- 
ways present, in the reparative process of cold-blooded animals. Ex- 
treme cold would altogether arrest the operation of repair. Dr. 
Greenhow of Xewcastle substitutes the "modelling process" for sup- 
puration in cases of recent burns, by forming an artificial scab for them, 
by liquefied resinous ointment, — and he states that he can prevent sup- 
puration even when large sloughs are thrown off. Constitutional treat- 
ment materially aids the adoption of judicious local measures. When 
inflammation threatens to run high, and convert the reparative process 
into a destructive and degrading one, it must be met by active anti- 
phlogistic means. If there be a tendency to low-toned inflammation, 
and there is not sufficient determination or richness of blood to cause 
an effusion of lymph, or if the lymph be not sufficiently plastic and or- 

1 Edinburgh Monthly Journal, Oct., 1851, p. 392. 

2 Pathological Transactions, vol. iv., p. 205. 



DEPOSITS — CACOPLASTIC. 



381 



ganizable, stimulants, and tonics, with nourishing diet, sometimes aided 
by the addition of cod liver oil, are highly serviceable. The power of 
a pure invigorating atmosphere to render the healing process healthy 
is often very remarkably illustrated. Nitric acid is sometimes useful, 
both internally and externally, probably on account of its oxygenating 
properties (§ 216.) When wounds are affected by congestion, rather 
than by determination of blood, and the effused plasma is converted 
into loose and spongy or fungous masses which project from the ge- 
neral surface, astringent and styptic applications are often of very de- 
cided service. 

For farther details on this subject, reference must be made to works 
on surgery. | 

Cacoplastie and aplastic deposits. 

554. Under various circumstances which have been alluded to in the 
preceding remarks, wounds or ulcers may be repaired by lymph which 
is cacoplastie or defective in organizability ; the cicatrix resulting from 
such imperfect repair is then lower in the scale of vitality than the 
texture in which it is produced. Thus in the skin, a tough, hard, 
opaque white fibro-cellular structure constitutes the cicatrix : the seams 
formed on the healing of scrofulous sores sometimes exhibit this cha- 
racter; the blood, in this case, not supplying a good plastic material. 
Sometimes the cause of degraded organization seems to be in the na- 
ture of the wound, or in some modification of the vessels of the part, 
or of the exudation from them, as in the scars which result from burns 
and scalds, and from certain kinds of poisoned wounds. In these cases, 
the cicatrix is dense and thick, and tends to further contraction, sub- 
sequently to its first formation, and this causes a puckering of the 
parts, and often great distortion of the integuments. Deposits similar 
to these cicatrices have been noticed in internal parts after chronic and 
scrofulous inflammation, (§ 479, 485,) and after congestion (§ 311;) 
the dense fibro-cellular and fibro-cartilap-inous formations that occur 
on and under serous membranes and in cellular textures are of this 
kind; and so also are the indurated interstitial structure which cha- 
racterizes cirrhosis, 1 and granular degeneration of the liver and kidneys, 
as well as certain scars and consolidations very commonly met with in 
the lungs. The opaque, tough thickening of the valves of the heart, 
occasionally attended by corrugation, contraction, and rupture, and 
the similar change which affects the coats of arteries, appear to belong 
to the same class. 

The structure of these deposits deserves to be more fully investigated. 
They appear to be more or less organized, being composed of irregular 
cells and nucleated fibres, imbedded in granular or amorphous solid 
matter in various proportions (§ 424.) Their organization, however, 
differs much in degree, some being vascular, and some not; but they 

1 The term cirrhosis (from the obsolete Greek word, xiooog, yellow,) was first applied 
by Laennec to the contractile disease of the liver; because the interstitial deposit which 
causes the contraction is often yellow from being stained with bile. The term is there- 
fore obviously inapplicable to contractile deposits in the lung and other parts ; to which 
the name has nevertheless been applied. The epithets, granular or contractile deposit, 
are more generally accurate as designations of these forms of cacoplastie product. 



382 



DISEASES OF STRUCTURE. 



are all inferior in this sense to the structure with which they are con- 
nected, and to the euplastic deposits above described. Although rarely 
occurring in great abundance in any organ or structure, except in con- 
sequence of some hyperemia of the part, yet in a small extent caco- 
plastic deposits are to be met with in most subjects at all advanced in 
life, more particularly in such as have long suffered from ill health. 
The opaque thickening of the membranes investing the liver, spleen, 
lungs, heart, and brain, often arborescent in arrangement from its ac- 
companying the course of the blood-vessels — the coarse and irregular 
granular appearance exhibited in limited patches of the liver and kid- 
neys, especially at their most depending portions, in which some of the 
granules are commonly adherent to the capsule of the viscus when it 
is torn off — the partial consolidations of the lungs, particularly near 
their apex — the opaque spots on the covering and lining membranes 
of the heart and arteries — are all specimens of cacoplastic deposits re- 
sulting from age and disease ; and the more the nutrient function has 
been degraded in the individual, the more abundant these deposits are 
found. Generally, however, they attack one organ in particular, in 
consequence of previous disease having predisposed it to suffer (§ 31, 
22.) Thus if a person has injured the function or structure of the 
liver or kidneys, by habits of intemperance, or in any other way, the 
injured organ is the first to suffer, and when, in the lapse of time, age 
begins to tell upon the nutritive function, it then becomes the subject 
of contractile or granular and fatty degeneration ; and this may de- 
stroy life by arresting circulation and excretion, &c, (§ 170, 311) be- 
fore other organs are much affected: hence the occurrence of dropsy, 
jaundice, albuminuria, &c. 

555. But there is another more general variety of cacoplastic de- 
posit, which takes place when textural nutrition is degraded still farther 
than in the preceding examples ; this is the semi-transparent, miliary, 
gray, and tough yelloio forms of tubercle. Instead of (with Laennec) 
classing tubercle under the vague term of "accidental productions," 
or (with Carswell) as a "secretion sui generis" I have for many years 
been induced to refer it to a degraded condition of the nutritive ma- 
terial from which old textures are renewed, and new ones formed; and 
to hold that in its origin it differs from the normal plasma or coagulable 
lymph, not in hind, but in degree, of vitality and capacity of organiza- 
tion. 1 These views have received almost demonstrative confirmation 
from the microscopic researches of Mr. Gulliver and others, which have 
detected in tubercle the materials of lymph, in a degenerated and con- 
fused state, the cells being few, irregular, and often shrivelled, with 
imperfect nuclei, which seem to be incapable of farther development; 
no fibres being perceptible, and the main substance being composed of 
granular or amorphous matter. 2 Every gradation may be found be- 

1 A somewhat similar opinion, but less definitely expressed, has been entertained by 
Dr. Alison, and formerly by M. Andral; but these pathologists seem originally to have 
regarded tubercle as being chiefly the product of a modified form of inflammation. 

a "Corpuscles more or less globular or oval are seen in tubercles; but the granular 
matter preponderates as the tubercular mass increases. Cells may be recognised In the 
miliary tubercles ; but as they increase in size, the well-marked and complete cells dis- 
appear. Tubercles appear to differ essentially from the plastic exudations, inasmuch as 



DEPOSITS — CACOPLASTIC — TUBERCLE. 



383 



tween euplastic and aplastic deposits; the cells and fibres which are 
the representatives of organization diminishing in number and com- 
pleteness, and the material becoming more granular, amorphous, or 
more abundant in fat globules, in proportion as the deposit is degraded, 
until, in opaque, crude, or yellow tubercle, it is altogether aplastic, 
consisting of a mere aggregation of granules and fat globules, inter- 
spersed with the mere traces or remains of cells. 

I consider that the more solid forms of tubercle are entitled to rank 
among cacoplastic deposits ; because, although destitute of vascularity, 
they seem to possess a kind of structure, like that of the lower kinds 
of fibro-cartilage and granular deposit. In the semi-transparent, gray, 
tough yellow, and miliary varieties, vestiges of cells and fibres are 
commonly seen. The affinity of these with granular degeneration 
(§ 544) and fibrous deposits is shown by their commonly occurring in 
the same subjects, and by their frequently exhibiting the same tendency 
to contraction. In a very large majority of cases of chronic granular 

the cells of the latter not only grow into a higher organization, hut increase in numher 
towards the centre; in other words, plastic matter has an inherent power of multiplying 
and evolving organic germs. But tubercle has no such power; for it would appear that 
its primitive cells can only retrograde and regenerate." (Gulliver's Appendix to Gerber's 
Anatomy, p. 87.) — "If a tubercle, or even the tissue of the lung near it, be slightly com- 
pressed between two slips of glass with a drop of water, it will crumble down and break 
to pieces, the fluid being at the same time quite white or milky. This white appearance 
is attributed to a great number of minute objects, the assemblage of which constitutes 
the substance of the tubercle. They consist for the most part of molecules, granules, 
and granulated corpuscles, of various sizes, of aggregated granules without any tunic, 
and of collapsed tunics without any granules. These objects are mingled with a great 
many shapeless flakes and filaments, which are no doubt fragments of the membrane of 
the air-cells, and of the minute blood-vessels, which, when involved in a tubercle, be- 
come so extremely brittle, that they must necessarily form a considerable proportion of 
the objects occupying the field of the microscope. The granulated corpuscles of a tuber- 
cle are sometimes very large, (one-eight-hundredth or one-thousandth of an inch;) and 
the molecules and granules, which are very conspicuous, may frequently be seen on the 
point of escaping from them. . . . The semi-transparent forms of tubercle and tu- 
bercular infiltrations owe their peculiarity to a great relative amount of granulated vesi- 
cles, {cells, Gulliver;) whereas the opaque white forms of tubercle are attributable to great 
numbers of isolated granules." — (Mr. Addison's "Experimental and Practical Researches," 
§c. ; Trans. Provincial Med. and Surg. Association, 1813, p. 287-8.) Rokitansky describes 
tubercle to consist of a more or less pellucid base, with elementary granules of various 
magnitudes, nucleus formations in various phases, and scanty nucleated cells. "The 
nuclei and cells are often to a great extent misshapen, disorderly, jagged, angular, bulging, 
dumb-bell-shaped, rudimental, stunted." (Pathol. Anat., Sydenham Soc. Trans., vol. i., 
p. 295.) — Rokitansky views tubercle in the light of an altered fibrin; and he considers 
miliary tubercles to correspond with the fibrinous, and the yellow tubercle with the 
croupous variety of lymph. 

Very similar appearances have been described by other writers; and although some 
have adhered to the notion of some peculiar form of cell or corpuscle as characterizing 
tubercle, the general inference is that tubercle is an imperfectly organized matter, without 
anything specific or distinctive in its constituent^particles. One of the most recent au- 
thors, M. Mandl, describes true tubercle as an amorphous matter, consisting of mere 
granules or molecules, and subject a3 unorganized albumen to fatty transformation. 
(Archives Gen. de Med., 1855.) 

These various observations supply microscopic evidence in favour of views regarding 
the nature of tubercle, which I have long held and taught, and to which I was led by an 
attentive examination of the common characters and changes of lymph, pus, and tubercle. 
A brief notice of these views may be found in the four editions of my little work on the 
"Pathology and Diagnosis of Diseases of the Chest," 1828—10; in my "Lectttres on the 
Diseases of the Chest," published in the "Medical Gazette," of 1837-8; and in the 
"Library of Practical Medicine," vol. iii., 1810. All these works were published long 
before any of the above microscopical examinations were made. 



384 



DISEASES OF STRUCTURE. 



disease of the kidneys or liver, there are found more or less traces of 
tubercle in the lungs, the chief seat of its deposition; and in very few 
instances of chronic phthisis have I failed to find some degree of gra- 
nular disease in the liver or kidneys. In acute phthisis and in acute 
granular disease, local causes accelerate the degenerative change to a 
destructive extent in one organ, before there is time for others to be- 
come affected. 

556. We now proceed to trace the history of cacoplastic deposits by 
a few examples. The dense false membranes formed on the surface of 
serous membranes may be often seen to be surrounded by a radiated 
wrinkling or puckering of the adjoining parts, indicating that the ab- 
normal substance has shrunk in size subsequently to its being first laid 
down. A similar contraction is noticed in the deposits that occur on 
and under the lining membrane of the heart and its valves, and here it 
causes a serious disturbance of the mechanism. The narrowing of the 
chest in some cases of pleurisy is, in part, dependent on the same pro- 
perty of cacoplastic deposits. This tendency of false membranes to 
contract was long since pointed out by Dr. Hodgkin and Laennec ; and 
the fact has been subsequently applied by Dr. Carswell to explain the 
diminished size of the liver in cirrhosis, which he considers to be due 
to a deposition in the intravascular filamentous texture prolonged from 
the capsule of Glisson. I do not myself think that the contractile de- 
posit in cirrhosis is exclusively confined to one texture, but believe that 
it is generally exuded from the distended blood-vessels. False mem- 
branes, which exhibit the same contractile character, are sometimes 
found on the free surface of serous membranes, and especially along 
the course of the vessels (veins as well as arteries ;) and depressions 
caused by atrophy of the substance of the organ beneath these deposits 
are sometimes seen in the liver and lung. There can be little doubt that 
these deposits originate in a fibrinous material exuded from the vessels 
in certain pathological states, (congestion, chronic inflammation, and 
mal-nutrition,) and forming a dense structure of low vitality, which 
tends, by its subsequent contraction, to constrict and compress the 
subjacent parts, and so more or less to interfere with the passage of 
blood through them, and consequently to derange their nutrition and 
vital operations. The same tendency is evinced in the higher (less 
aplastic) forms of tuberculous disease. Miliary or granular tubercles 
in the lungs, when in considerable numbers, and not soon softening, 
cause a contraction of the substance of the organ, chiefly at the upper 
part, and a corresponding collapse in this portion of the chest. I 
have met with many cases, in which a sinking in of the infra-clavian 
region has taken place before any symptoms of softening or excavation 
have occurred; indeed this is a very common sign of the presence of 
tubercles which remain long stationary. The still greater amount of 
structural collapse, in the advanced stages of tuberculous lesions, al- 
though partly dependent on other causes, is also still in some degree 
connected with the contraction of cacoplastic deposits in the lungs and 
pleura. In the peritoneum agglutinated tubercles often cause consi- 
derable contraction ; I have seen the omentum puckered up by them 
into a knotty mass. 



DEPOSITS — TUBERCLE. GRAY AND CRUDE. 



385 



The microscopic examination of cacoplastic deposits at different 
stages of their formation, throws considerable light upon the true na- 
ture of this process. When recent, the effused matter consists of fibres 
with a great quantity of granular, and more or less of amorphous sub- 
stance, with or without an admixture of cells. At a later period, and 
after it has contracted, it is much more tough, and it is then found to 
be more distinctly fibrous, much of the granular and amorphous matter 
having disappeared. Old contractile adhesions and cicatrices are still 
denser, and when examined by the microscope are seen to consist al- 
most entirely of closely interwoven fibres, differing from those of fibro- 
cartilaginous tissue only in being less regular and distinct. Gray or 
granular tubercles wither and become more tough or horny ("cornify " 
— Rokitanshj) and thus remain quiescent. It appears therefore that 
it is by the partial absorption of the granular and amorphous portion 
of the deposit and by the closer approximation of the fibrous, or more 
organized constituent, that the condensation takes place. Hence it is, 
that the structure so contracted is subsequently less liable to the 
further degeneration to which cacoplastic deposits are prone. Certain 
it is, that of different portions of cacoplastic deposit in the lungs and 
elsewhere, those that are contracted remain unchanged, whilst the rest- 
pass into the aplastic state of opaque and softened tubercle. The con- 
tractile process seems, therefore, to raise the deposit to a higher stan- 
dard, so that although still inferior in vitality to the adjoining textures, 
it gets to be tolerated by them, so to speak. But this very change 
may seriously injure the textures of organs, by contracting and com- 
pressing their vessels, and interfering with their nutrition and other 
functions, and in this respect therefore it may be compared with the 
highest, or most annualized variety of degeneration, the fibrous, which 
has already been described (§ 543.) It is in this way that the con- 
tractile diseases of the liver and kidneys gradually infringe on the cir- 
culation and secretion of these organs, and eventually prove fatal 
(§ 249, 375.) The contraction which takes place near the apices and 
roots of the lungs, in the more limited and therefore more chronic va- 
rieties of pulmonary tuberculous disease, often lays the foundation of 
emphysema of the organ and habitual asthma. I have notes of a large 
number of cases illustrative of this fact: but such details belong rather 
to special than to general pathology, and are reserved for another 
work. It is a similar change in the deposit formed under the mucous 
membranes of the alimentary and urinary passages that constitutes the 
strictures, which cause so much distress and disorder in these canals. 

557. Having described the less degraded and degenerating form of 
cacoplastic deposits, it now remains to notice the variety which is of a 
lower character, and which tends to become aplastic. This includes all 
the commoner forms of tubercle. In the granular, miliary gray, or 
drab-coloured tubercles of serous membranes and of the parenchy- 
mata of organs, there is found a dense homogeneous solid, closely re- 
sembling some of the cacoplastic deposits which have just been de- 
scribed. The resemblance, and even identity of these, may often be 
very well traced out in chronic or subacute arachnitis, peritonitis, and 
pleuritis ; portions of the affected membrane are covered with diffused 
25 



386 



DISEASES OF STRUCTURE. 



patches of semi-opaque deposit, which no one would hesitate to call false 
membrane ; whilst in other parts separate granules of precisely the same 
deposit exhibit all the characters of granular or miliary tubercle. But 
(it maybe asked) how comes it here to assume the granular form? 
The answer to this question will be found in the observations pre- 
viously made, on the products of inflammation (§ 449,) where it was 
pointed out that the effusion of lymph on an inflamed membrane is at 
first granular, and that it would continue to be so, if it were not drawn 
or spread into threads or films by the friction or pressure of the sur- 
faces where it is poured out ; several examples were there cited, to 
show that in the absence of such friction or pressure, the granular ap- 
pearance is preserved even in acute inflammation. In scrofulous and 
chronic inflammation, the matter effused is from the first less ductile 
and more consistent, and the granular condition consequently more 
generally prevails and remains even in spite of pressure and friction : 
and it is admitted, that the product of chronic inflammation of the pe- 
ritoneum and of the arachnoid membrane is always more or less gra- 
nular. In acute inflammation in tuberculous subjects, recent lymph is 
commonly studded with opaque granules, which subsequently assume 
the character of tubercles. 

But tubercular deposit is not always preceded by inflammation. In 
many cases, tubercles are found so extensively disseminated through 
different textures, after few or no symptoms of inflammation, that it is 
quite impossible to regard them otherwise than as the result of modi- 
fied textural nutrition. The cell-germs by which the organized fabric 
is renewed, are imperfect at particular points ; granular or amorphous 
matter is deposited at each of these from the plasma, and concretes 
without fibres or regular cells being developed in it ; and a granula- 
tion then appears, and gradually hardens. Where a granule has once 
been formed, it becomes a nucleus for further concretion : a new ha- 
bit or mode of nourishment is established at the spot; or, to speak less 
figuratively, the cacoplastic matter present in the blood plasma is 
drawn thither by a process similar to that by which fat attracts fat, or 
bone attracts osseous particles; perhaps this process is not altogether 
different from crystallization, a supposition strengthened by the fact 
that in Mr. Gulliver's experiments a deposit of new osseous matter 
occurred in dead bone which had been placed within a living inflamed 
one. (Med. Chir. Trans., vol. xxi.) But however this may be, the re- 
sult is, that the granular tubercle grows until it attains the size of a 
millet-seed, a hemp seed, or rarely even that of a small cherry-stone: 
if subjected to pressure, it slightly spreads or flattens into various shapes. 

The microscopic character of these miliary or granular tubercles is 
the abundant presence of minute and often irregular granules, and the 
comparative absence of fibres and ceils, of which mere traces only can 
be seen, at least in the older specimens. The granules are aggregated 
together by an amorphous material, the solidity of which gives hard- 
ness and some translucency to the mass ; acetic acid and alkalies dis- 
solve or make transparent this cement, loosen the granules, and ren- 
der them distinct. In chemical nature granular tubercle is albuminous 
with a little fat in its composition; the latter in minute molecules here 



DEPOSITS — APLASTIC — YELLOW TUBERCLE. 



387 



and there, occupying chiefly the centre of the granules; the albumen 
probably constituting the amorphous cement alluded to above- In all 
this there is a close analogy to the granular degeneration of textures 
(§ 544,) of which doubtless tubercular deposition is but a kind of ex- 
aggeration. 

Miliary tubercles exhibit a considerable variety in size and consis- 
tence according to their age. When recently formed, they are plump, , 
and although feeling harder than the surrounding texture, yet they can 
be crushed with firm pressure between the fingers. But in lapse of 
time they contract in size and become tougher, so that no pressure can 
crush them. This change, termed by Rokitansky, Oornefaction, is in 
the lung accompanied by a darkening of colour, so that old tubercles 
are often quite black. This is usually an indication of the tubercle 
having become quiescent or obsolete, and having little tendency to de- 
generation into the yellow form. 

558. Tubercles rarely occur in numbers or spread much without ex- 
hibiting another change of appearance. They lose their semi-trans- 
parency, and become of an opaque or dead pale-yellow hue, like the 
colour of raw potato or parsnip. This marks the transformation to crude 
yellow tubercle first described by Laennec; and this is the result of a 
farther degradation or degeneration of the deposit. The few fibres 
and cells which are to be detected in gray tubercle are no longer dis- 
tinguishable here, interstitial hyaline or amorphous solid is greatly 
diminished, oil globules appear in its stead, and the mass becomes pro- 
portionally less coherent and more granular, and is now indeed quite 
aplastic. Generally the change begins in the centre of the mass ; appa- 
rently because, there being no permeating vessels, the centre is the far- 
thest removed from the vivifying influence of the blood. The cornea, and 
other non-vascular textures, occasionally become opaque in a similar 
way in consequence of deficient supply of sustaining nutriment in the 
plasma, and may indeed entirely lose their organization (§ 269.) A 
parallel form of degradation is that which is observed in the degenera- 
tion of fibrous and cellular tissues into granular matter, recently pointed 
out as resulting from mal-nutrition (§ 544.) But not only will deficient 
supply of healthy plasma promote the transformation of tubercle from 
gray to opaque ; an undue flow or accumulation of blood, produced by 
congestion or inflammation in the neighbourhood, will also accelerate 
the change, just as the same occurrence hastens the disintegration of 
lymph and of compressed textures, the conversion of the plastic into 
the aplastic, through the increased warmth and afflux of fluids exalting 
chemical affinities in a material which has none of that vital power of 
resistance by which living tissues maintain their integrity. 

559. But tubercle is frequently deposited at first in this yellow, 
opaque state ; this circumstance then indicates the still more degraded 
condition of the nutritive function: the most extensive forms of tuber- 
culous disease commonly present most of this aplastic matter. In rapid 
phthisis, whether resulting from acute inflammation in a scrofulous sub- 
ject, or from the excessive prevalence of a scrofulous diathesis (caco- 
plastic matter in the blood) yellow tubercle generally forms a large 
portion of the deposit ; and it is in these cases that its resemblance to, 



388 



DISEASES OE STRUCTURE. 



and connexion with, coagulable lymph, may be best seen. 1 Yellow 
tubercle is rarely so hard or so tough as the gray or semi-transparent 
kind ; and in such cases of rapid deposit as those just mentioned, it is 
often very much softer and more friable. Now, this state marks the 
commencement of a change to which the lowest forms of tubercle par- 
ticularly tend — that, namely, of maturation and softening into a sub- 
stance of cheesy consistence. The conversion of gray into opaque tu- 
bercle, and the subsequent farther softening of the latter, seems to be 
the converse of the contractile process to which the higher class of 
cacoplastic deposits are prone : in that (the contractile process) the de- 
posit becomes more dense and organized : in this (opaque change and 
softening,) it becomes less dense, and loses the little trace of structure 
which it possessed; it degenerates into an amorphous granular mass; 
and being lifeless it is no longer nourished ; but its granules lose their 
cohesion, and become disintegrated by spontaneous softening, aided 
by the chemical action of the adjoining fluids. Mr. Gulliver long ago 
noticed that there is a remarkable increase of fat globules in softened 
tubercle, and this has been confirmed by many subsequent observers. 
In fact, from the time that tubercle begins to assume the opaque form, 
oil globules appear to increase in it, and this goes on until it is either 
softened and eliminated, or has undergone the p§trifactive change to 
be described hereafter. The conversion of gray into yellow tubercle, 
and the maturation and softening of the latter, appear therefore to be 
dependent on a fatty degeneration, resembling that which takes place 
in fibrinous deposits (§ 454,) and in nourished textures (§ 545.) 

The increase of fatty particles in old pus (§ 460,) in the atheroma 
of arteries, and in the chronic inflammatory deposits and gangrene of 
the lungs, was adduced in the former editions to show, that fat is some- 
times a debris of animal matter, as it is when flesh out of the body is 
converted into adipocire (§ 543.) The detection, by Dr. Davy, of 
oleine and margarine in opaque exudation corpuscles in the lungs (§ 543) 
and the observation, by myself and others, of numerous fat globules in 
deposits in the kidneys and spleen, and in the vegetations on the valves 
of the heart, were formerly adduced to show a tendency to the pro- 
duction of fat in all degenerated plasmata ; and fatty degeneration in 
the minute arteries of the brain, in the kidneys, and in other organs, has 
long since been described by Mr. Gulliver : 2 but the most complete con- 
firmation of this view is to be found in the researches of Dr. R. Quain, 
before alluded to (§ 545,) and in several subsequent contributions on 
fatty degeneration, especially in the discovery by Kilian and Rainey, 
of fatty transformation of the uterus after parturition. In many in- 
stances the fatty matter presents itself in a solid form, (either crystal- 
lized or in granules,) rather than as distinct oil globules ; and this fact 
suggests that a change has occurred in the quality, as well as in the 
quantity, of the fat that is contained in the deposits, and that this pro- 

1 The affinity between lymph and tubercle was recognised by some of the older writers ; 
and after it had been kept out of view by the too exclusive adoption of the opinions 
of Bayle and Laennec, it was again pointed out by Dr. Alison. (Trans, of Meclico- 
Chirurg. Soc. of Edin., vols. i. and iii.) 

2 Edinburgh Med. and Surgical Journal, 1843; and Med. Chir. Trans., 1843. 



DEPOSITS — APLASTIC — YELLOW TUBERCLE. 



389 



bably prevents its absorption. These considerations which have before 
been noticed in the paragraph devoted to fatty degeneration (§ 545,) 
prove that morbid deposits are amenable to the law of fatty or hydro- 
carbonaceous transformation in common with natural structures; and 
that they are indeed more liable to this sinking in the scale of organic 
composition in consequence of their low vitality, and of their extravascu- 
lar position placing them beyond the reach of the decarbonizing influence 
of the circulating blood. As the change is in a great measure spon- 
taneous, and as it is promoted by moderate moisture, it increases with 
the age of the tubercle, within certain limits, beyond which the mineral 
transformation or petrifaction ensues. But if the deposit be still far- 
ther deprived of the preserving influence of the living textures, whilst 
it is kept moist by the exhalation from the surrounding congested ves- 
sels, a softening and decomposition more rapid and offensive than that 
of fatty degeneration may take place ; and in extreme cases verges 
upon gangrene. Thus when many tubercles soften early and largely, 
they do so by a decomposition which is more rapidly destructive ; and 
this, by generating matter that is offensive to the adjoining textures 
and to the whole frame, causes the local and constitutional irritation, 
so strongly marked in acute cases of a phthisical kind. 

560. In these successive changes of tuberculous matter, as well as 
in its original deposition, the adjacent living parts have an intimate 
concern. A miliary tubercle may cause irritation and obstruction to 
the contiguous textures from its first formation. The extent to which 
it does this depends on the natural or acquired vascularity and excita- 
bility of the part, the character of its function, and the precise situa- 
tion and size of the tuberculous deposit. Thus, there is more tendency 
to mischief and rapid change in vascular and parenchymatous textures 
than in serous membranes. When the irritation is very slight, it may 
merely lead to so much determination of blood as will promote the 
growth of the gray tubercle. When it is more severe, it may cause 
the conversion of gray into yellow tubercle, its farther increase in this 
form, and its softening. If the irritation be still greater, inflamma- 
tion is excited around the deposit ; traces of its existence are often seen 
after death in the form of an areola of vascular redness ; the products 
of this inflammation (pus, lymph, mucus, and serum,) tend to hasten 
the softening of the tubercle, and the evacuation of its substance, min- 
gled with their own, by ulceration through adjoining open surfaces. Or, 
being more solid and plastic, they lead to the formation of consolida- 
tions, or false membranes, around the tubercle, and so to the limitation 
of the irritating influence. Thus, although, as just stated, the opacity, 
maturation, and softening of tubercle depend essentially on progressive 
degeneration and destruction, these changes are nevertheless hastened 
and modified by the afflux of blood to the neighbouring parts. 

561. In the absence of the circumstances specified above, as tending 
to promote the increase or the farther change of tubercle, it may re- 
main comparatively harmless for months, and even for years, subse- 
quently to its first deposition ; but then it often exhibits a peculiar 
transformation which may be considered to be more spontaneous and 
of a chemical nature. This is altogether different from the change of 



\ 



390 DISEASES OE STRUCTURE. 

the less cacoplastic forms by contraction, already noticed as implying 
an elevation of the deposit to the condition of a fibrous tissue, nourished 
and preserved as a living part. In the lungs, consolidations commonly 
remain for a long time without any contraction, and become deeply 
blackened by an accumulation of the peculiar colouring matter of the 
pulmonary texture. But yellow and softened tubercle, if not evacuated, 
in time becomes replaced by a plastery or putty-like matter, composed 
chiefly of phosphate and carbonate of lime, and often containing solid 
concretions, consisting entirely of such earthy matter. This petrifac- 
tive transformation recalls to mind what has been spoken of in relation 
to cacoplastic depositions in the coats of arteries, and on serous mem- 
branes (§ 544, 553,) and as constituting the structural alteration that 
is erroneously called ossification ; and it establishes the fourth and last 
parallel which connects tubercular change with the degenerations that 
kindred textures undergo from the influence of age or disease ; — that, 
namely, of osseous or mineral transformation. The calcareous con- 
version of tubercle can be explained only on the supposition that or- 
ganic matter is absorbed, and the earthy salt deposited in its place. 
This is exactly what happens in the true petrifaction of organized bodies, 
the silica or calcareous substance being substituted molecule for mole- 
cule, for the organic principles: so that when there is nothing remain- 
ing but the stone, it is moulded in the original form of the organized 
body. This is very important, inasmuch as it proves that the animal 
matter of tubercles may be absorbed. The occasional absorption of 
tuberculous matter is also illustrated by its accumulation in the bron- 
chial and mesenteric glands, which sometimes contain it when the lungs 
and the intestines present only cicatrices, with some cretaceous matter 
in them. Tubercle very commonly exhibits the petrifactive change in 
the bronchial glands too ; the concretions often found in these situations 
may generally be ascribed to this source. 

562. The circumstances which degrade the material of nutrition, and 
lead to the deposition of cacoplastic and aplastic matter, may be either 
local or general. Of the local causes, congestion and the lowest and 
most chronic forms of inflammation have been already mentioned as 
capable of determining cacoplastic deposits ; but even in these cases 
it is probable that the general cause also more or less operates — that 
is, a degraded state of the plasma of the blood. Congestions and 
chronic inflammations certainly do cause cacoplastic deposits ; but then, 
such congestions and chronic inflammations do not easily occur in 
healthy subjects; and the want of health implies that there is some 
fault in the blood plasma. Practically, it is, however, of very great 
importance that the local as well as the general influence should be kept 
in view, for the former is often more tractable than the latter, and by 
obviating it, slighter degrees of disorder of the plasma may be pre- 
vented from doing mischief. The general cause, when present in high 
degree, leads nevertheless to cacoplastic and aplastic deposition, as a 
mere modification of ordinary textural nutrition, and independently of 
the occurrence of inflammation, or even of congestion. It then con- 
stitutes the chief element of the scrofulous diathesis or tuberculous ca- 
chexia, and as has been before stated, the most obvious physical con- 



DEPOSITS — TUBERCLE — SITUATIONS. 



391 



clition in this is defect of the red corpuscles and excess of the fibrin in 
the blood (§ 185, 211.) In this condition of the circulating fluid there 
is an increased disposition to deposit, and often an abundance of the 
plastic or crude nutritive material, but there is also an imperfect vita- 
lity or organizability of this material, so that when deposited, instead 
of being completely assimilated to the textures, it forms the degenerated 
structures or mere granular or amorphous substances which have been 
described. But when this condition of the nutritive fluid is present, 
such low deposits must be promoted by all varieties of hyperemia, and 
they must also abound most in organs which receive the largest amount 
of blood. Where most blood goes, there too the most of its depravity 
must be carried. Hence, the peculiarly pernicious effect of inflamma- 
tion of internal organs, and especially of the lungs, in scrofulous sub- 
jects. Even acute inflammation is then too often unable to raise the 
nutritive material to that plastic standard in which it can be organized 
or absorbed, or to place it in that condition in which it can be sub- 
jected to the process of complete suppuration whereby it maybe speedily 
excreted ; and the matter thrown out is merely cacoplastic or curdy 
lymph, remarkable for its opacity and want of cohesion, or it is a ca- 
seous kind of pus, inorganizable, inert, irremovable by absorption, and 
permanently obstructing or compressing the structures in which it ac- 
cumulates, until it gradually excites an irregular destructive suppura- 
tion or ulceration in them, forming vomicae, or imperfect abscesses per- 
vading their substance, and destitute of walls capable of carrying on 
the healing process: under the depressing and irritating influence of 
the morbid matter decaying and becoming decomposed, the body wastes 
and is harassed with hectic fever, night-sweats, and colliquative diar- 
rhoea. So likewise fevers, by causing congestions in organs, may lead 
to the production' of a crop of these deposits, and so ultimately to tu- 
berculous disease. 

563. The lungs and bronchial glands are far more commonly the 
seat of tubercles than any other parts ; when found elsewhere, they are 
nearly always yet more abundantly present, and in more advanced 
stages, in these parts. But the situation of the more marked develop- 
ment of tuberculous disease varies also with the age of the subject. 
Thus, M. Papavoine found that in children yellow tubercle occurs most 
frequently and abundantly in the cervical and mesenteric glands ; next 
in the spleen, pleura, liver, and small intestines ; then in the large in- 
testines and peritoneum ; and more rarely in other parts. In 350 con- 
sumptive cases (chiefly adult) examined by M. Louis, there were tuber- 
cles in the small intestines in one-third of the whole ; in the mesenteric 
glands, in one-fourth ; in the large intestines, in a ninth ; in the cervi- 
cal glands, in a tenth ; in the lumbar glands in a twelfth ; in the spleen 
in a fourteenth ; and in other organs in smaller proportions. 

The greater liability of the lungs to tuberculous deposits, has been 
ascribed by some writers to the finer size of their capillary vessels, 
which act as filters to the blood, arresting the tuberculous matter al- 
ready in a solid state in that fluid. But this view is untenable for se- 
veral reasons. 1. If the fine size of capillaries were the chief cause 
of the deposit, it should also take place abundantly in muscle, the ca- 



892 



DISEASES OE STRUCTURE. 



pillaries of which tissue are even finer than those of the lungs. 2. If 
the solid matter were first arrested mechanically in consequence of its 
obstructing small vessels, the appearance of vascular distention would 
he obvious from the first, and the deposit would exhibit somewhat of a 
capilliform shape; this however is not the case. 3. The deposit has 
been distinctly traced by Messrs. Gulliver, Addison, Hainey, and others 
to be extravascular, sometimes lying on the surface of the air-cells, 
and sometimes in or under the membrane composing them. 1 I think 
it highly probable that tuberculous matter may form within the blood- 
vessels themselves. I have repeatedly found matter presenting all the 
external characters of yellow tubercle in the blood-vessels of tubercu- 
lous lungs. 2 In fact wherever fibrin can coagulate, there its degraded 
form, tubercle, may occur; and I cannot but refer in support of this 
view to the opaque softening of clots of fibrin in coagula in the heart 
and great blood-vessels. Formerly, this softened fibrin was mistaken 
for pus ; but Mr. Gulliver has pointed out this error by showing that 
it had no characteristic cells. Its aspect and microscopic composition 
in reality differ in no essential particular from those of soft tubercle. 
This leads me to infer that the fibrin of blood when stagnant within 
vessels, or extravasated from them, may, in tuberculous subjects, some- 
times change into aplastic tubercle. But the reasons already advanced 
make it obvious that in its early form tubercle is an extravascular de- 
posit, resulting from modifications of the ordinary nutritive secretion. 

I believe that several circumstances contribute to render the lungs 
especially liable to tuberculous deposit. 1. Their great vascularity 
and the large quantity of blood that passes through them, makes them, 
in a proportionally large amount, partake of any disorder in the con- 
dition of this fluid. 2. Their functions being in a degree connected 
with the formation of fibrin, for that principle is more abundant in 
arterial than in venous blood (§ 194.) 3. The softness and yielding 
nature of their texture, which permits effusion to take place in it more 
readily than it can in denser parts. 4. Their exposure to the irri- 
tations of cold and other influences entering by the air-tubes, and to 
derangements operating through the medium of the circulation, ren- 
ders them particularly obnoxious to such disturbance as is apt to give 
rise to the first deposition. In hot climates, cacoplastic diseases affect 
the liver and other abdominal viscera more than the lungs; the same 

1 Pulmonary tubercle has been described by Tan der Kolk, Addison, and R. Hall, to 
originate in a diseased state of the epithelium of the air-cells of the lungs. But the very 
existence of this epithelium is denied by Mr. Rainey, a very accurate observer; and it 
seems probable that the appearances of enlarged and fatty epithelium-cells, are derived 
from the adjoining bronchial tubes. Dr. R. Hail (Brit, and Foreign Med. Chir. Review, 
Oct., 1855,) like Gruby, Lebert, and others, ascribes to tubercles a peculiar form of cells, 
but my own observations coincide with those of Gulliver, Rokitansky, and Mandl, -which 
discovered none but abortive, withered or mis-shapen cells, vrith abundant granular or 
hyaline matter, in simple tubercle. When it softens there is more appearance of cells, 
both from portions of granular matter becoming enveloped, and from the addition of in- 
flammatory exudation cells. In ail these observations it should not be forgotten how 
readily granules, oil-globules, and even blood-corpuscles acquire an extemporaneous in- 
vestiture of an albuminous film, which gives them at once the aspect of cells. 

2 Rokitansky mentions the occurrence, in the blood-vessels, of coagula of a tuberculous 
nature. — Path. Andtomy, Syd. Soc. Trans., vol. i., p. 305. 



DEPOSITS — CACOPLASTIC AND APLASTIC — TREATMENT. 393 



persons there suffering from chronic liver disease and dysentery, who, 
in a cold climate would fall victims to phthisis. 1 

564. As it has been seen (§ 562) that the cacoplastic condition of 
the blood of tuberculous or scrofulous subjects is connected with dimi- 
nution of the red corpuscles and a preponderance of fibrin, so it may 
be stated that whatever tends to effect these changes is very apt to in- 
duce tubercle. Insufficient food, want of pure dry air, of warmth, and 
of light, long-continued mental depression, aggravated and prolonged 
disorder of the digestive organs, insufficient excretion (§ 249,) and the 
occurrence of severe fevers and other analogous complaints, are ac- 
knowledged causes of both the general, and local development of tu- 
berculous disease. Excessive evacuations of blood, or of the more ani- 
malized secretions, and severe courses of mercury, also predispose to 
phthisis, and most probably operate mainly by diminishing the quantity 
of the red corpuscles, and by injuring the quality of the plasma. The 
cessation of growth, the termination of pregnancy, the stoppage of ha- 
bitual discharges, especially if they be purulent, and the amputation 
of a limb, are all circumstances well known to favour the development 
of tubercle, and they may be supposed to act chiefly by increasing the 
proportion of fibrin in the blood, when there is not a sufficiency of red 
corpuscles and of vital power, which is represented by them, (§ 183) to 
secure a due amount of elaboration for the higher purposes of life. 

565. The treatment of cacoplastic and aplastic deposits, and of the 
conditions which lead to them, involves a vast amount of detail when 
all the circumstances relating to kind, situation, extent, and other 
occasional peculiarities are taken into account. It does not accord with 
the scope of this work to enter upon the consideration of these details; 
but a sketch of the rational principles of treatment, based on the state- 
ments and explanations already offered, will not be out of place in its 
pages. It will be my object that this sketch should particularize such 
practical measures as have the fullest sanction of experience. 

The elements of cacoplastic diseases chiefly to be kept in view in 
considering the treatment are : — 1. The disordered condition of the blood, 
and its causes; 2. The disordered distribution of the blood, and its 

1 Mr. Simon and Mr. Ancell consider the tubercular diathesis to "be due to deranged 
development of the proteinaceous constituents of the blood, whereby something is solidi- 
fied, -which should remain fluid. This, however, Mr. Simon attributes to the oxydation 
of the proteinaceous principle, a process very apt to be effected in the glands where lymph 
is brought into contact with arterial blood, and in the lungs where it is mingled with the 
oxygen of the atmosphere. Rokitansky maintains that venosity of blood is opposed to 
the development of tubercle. On the other hand, in Dr. T. K. Chambers's examination 
of 2500 cases recorded in the post-mortem books of St. George's Hospital, the liability to 
tuberculoses seemed to be in proportion to the degree of venosity in the part. This 
should indicate that the great flux of venous blood to the lungs may have more to do with 
their proneness to the latter, than the abundant supply of oxygen. My own experience 
agrees with the inference of Rokitansky; for I have observed that organic diseases of 
the heart, spasmodic asthma, and pulmonary emphysema, all of which increase the ve- 
nosity of the blood, resist or retard the deposition of tubercles. It has repeatedly hap- 
pened to me to meet with a member of a phthisical family affected with morbus cordis, 
or spasmodic asthma, who has survived the age at which other members have been at- 
tacked with phthisis. It is nevertheless true that congestion of the lungs, as in fever 
293,) favours the development of tubercles, but congestion is not identical with ve- 
nosity. 



394 



DISEASES OF STRUCTURE. 



causes; and 3. The 'presence of the deposit, its intrinsic changes, and 
its effects. 

The more constant and important condition to be considered in the 
treatment of cacoplastic and aplastic diseases, is the one first named — 
the depraved state of the blood ; and this is of more consequence in 
treatment, and demands more attention according as the deposits are 
more extensive or degraded. The first point to be attempted is the 
removal or counteraction of the several causes already enumerated 
(§ 564,) as contributing to induce the diseased condition of the blood. 
Thus a sufficient supply of food of a nutritive and digestible quality, 
and especially comprising proteinaceous articles (§ 60) of the highest 
order; free access to pure dry air and to light, "while the warmth of 
the body, and particularly of the surface and extremities, is carefully 
secured by adequate clothing, and regular exercise proportioned to the 
strength — the removal or counteraction (so far as is possible) of de- 
rangements of digestion and excretion, and of depressing mental or 
bodily influences; — these are all objects that should be assiduously 
aimed at. When excessive losses of blood, or other evacuations, have 
lowered the plastic powers of nutrition, a generous animal diet, and 
tonics, especially such as contain iron, are especially demanded. Where 
the altered condition of the blood can be traced to an excess of ill-de- 
veloped fibrin accumulating after the cessation of growth, the termina- 
tion of pregnancy, the amputation of a limb, or the sudden stoppage of 
an habitual discharge, purulent or otherwise, means should be taken to 
eliminate the superfluous matter from the system, either by increasing 
the natural secretions, or by establishing an artificial drain through 
blisters, setons, issues, or suppurating counter-irritants; whilst tonic 
and invigorating measures are also adopted to raise the plasticity of 
the blood to a higher standard. Some of the remedies, to be more fully 
alluded to in relation to the third class of considerations, are occasion- 
ally effective in promoting these objects also, such as cod-liver oil, nitric 
acid, and combinations of iodine, which have a direct influence on the 
nutritive functions. 

The foregoing measures are preventive rather than curative ; but in so 
far as they may succeed in arresting the augmentation of deposits already 
formed, and in improving the nutritive function in general, they may be 
looked to cause the gradual absorption of tubercles, or their quiescence 
in contraction (§ 556) or calcareous transformation (§ 561.) 

566. The second element to be borne in mind, in relation to treat- 
ment, namely, disordered distribution of blood, and its causes, is iden- 
tical with the varieties of local hyperemia, which have been fully no- 
ticed as concerned in producing the higher kinds of cacoplastic deposits 
(§ 553,) and in promoting the formation and changes of that of a still 
lower character (§ 560.) Hence the measures that are appropriate to 
remove determination of blood and congestion are often serviceable in 
the prevention or treatment of cacoplastic deposits ; but it is very rarely 
that other than topical forms are required, such as local blood-letting, 
the application of counter-irritation, and the use of revulsives and de- 
rivants (§ 174.) ISTo remedial influences of this class have proved in 
my hands more generally useful than the milder counter-irritants, and 



INDICATIONS OF TREATMENT. 395 

rubefacients extensively and regularly applied by friction over a large 
extent of skin. They act not only as revulsives, diminishing the con- 
gestions and irritations of internal organs; but they also, by increasing 
a free circulation of the surface, promote the purification of the blood 
by perspiratory excretion, and by some degree of oxidation by the ac- 
tion of the air. 

567. The third class of objects to be regarded in treatment, relates 
to the deposit that is already formed, and the possibility of its removal 
or reduction to a quiescent and harmless state. This latter end is not 
easily attained, because the deposits are for the most part non-vascular, 
and but little under the influence of absorption and of the blood-cur- 
rents by which all organic changes are carried on. These substances 
being unlike to the products of inflammation, and to simply overgrown 
texture, the changes of absorption are necessarily slow in reaching them, 
solid and remote from vessels as they are ; and it is doubtful whether 
any remedial influence that can be brought to bear upon them has really 
the power to effect their removal, otherwise than by the simultaneous 
destruction of the texture in which they are contained. Mercury 
pushed so as to affect the gums, does seem to me to hasten the soften- 
ing and evacuation of pulmonary tubercles ; but it does this by such a 
work of destruction, that its agency is, on the whole, injurious rather 
than beneficial. Drs. Graves and Stokes, as well as other physicians, 
have, however, recommended that mercury should be given in the ear- 
liest stage of tuberculous disease. My own experience leads me to 
avoid the specific influence of mercury in all cases of mere tubercle ; 
but I have often employed it with advantage in subacute and chronic 
inflammation simulating tuberculous disorder, and even where tubercle 
probably co-existed in a limited extent. I am less doubtful of the 
utility of mercury (introduced by the skin) in incipient cacoplastic or 
tuberculous deposit upon serous membranes, and particularly on the 
peritoneum, which is commonly one of the results of chronic inflamma- 
tion. I have successfully treated several cases, in which the signs and 
symptoms left no doubt as to the existence of tuberculous peritonitis, 
by applying ointment of iodide of mercury to the abdomen (covering 
the skin with India rubber cloth,) and giving iodide of potassium in- 
ternally. Whether mercury is of any use in granular disease of the 
liver and kidney, is a matter of considerable doubt. Alkalies and their 
carbonates, and iodide of potassium have better claims to attention, 
although it is by no means certain that they possess much power. The 
occasional subsidence of external scrofulous tumours under their exhi- 
bition, is the best argument in their favour; and there is this advan- 
tage attending their employment, that when judiciously administered 
for long periods, they do not materially injure either the blood or the 
constitution. They act best, and are borne the longest, when com- 
bined with some amylaceous or mucilaginous compound, such as decoc- 
tion of Iceland moss, or fluid extract of sarsaparilla, to which may be 
added a little tincture of hop, or some other bitter. I have found this 
combination useful in the early stages of tuberculous disease, where 
there was no fever, active inflammation, or tendency to hemorrhage. 
Whether the iodine and alkali ever directly promote the solution or ab- 



396 STRUCTURAL DISEASES — DEPOSITS. TUBERCLE. 



sorption of tuberculous matter, I am still in doubt; but I am clear that the 
signs of the presence of limited tubercles have, in many instances, dimi- 
nished during their use, and the patients have regained colour, flesh, and 
strength. Other combinations of iodine, particularly with iron, have 
also been recommended in scrofulous disease. The iodide of iron, and 
chalybeates in general, are decidedly beneficial in cases of anaemia or 
weakness in scrofulous- subjects, without much fever or local inflamma- 
tion ; but I have no reason for believing that they actually promote the 
removal of tubercles already found. 

568. But there are yet other agents, which have been found to be 
of decided efficacy in cacoplastic and aplastic diseases, whose mode of 
operation may be intimately connected with some of the considerations 
we have recently been entertaining. It has been seen that cacoplastic 
deposits consist of granular albumen or protein, with a little (insoluble) 
gelatine, and minute molecules of fat contained in the granules; and 
that the more granular the deposit, and the lower it is in the scale of 
organization, the more the fatty molecules abound, being so much in- 
creased in opaque tubercle and atheroma, that they coalesce and form 
large oil globules, and sometimes solid concretions of fat. The most 
effectual solvents of all these constituents are caustic alkalies, and espe- 
cially the liquor potasses, which dissolve protein, and form a liquid 
soap with oil. But it is impossible to administer these agents in suffi- 
cient quantity to obtain their influence through the blood, both because 
they would irritate the stomach and vessels too much during their pas- 
sage, and because they would soon meet with such an amount of acid, 
(particularly the carbonic,) as would deprive them of the greater part 
of their solvent power. The same remark applies to the employment 
of acetic acid, which has been also recommended as a solvent of solid 
albumen. 

Other agents which have been extolled as remedies for tuberculosis 
might be supposed to act by dissolving the fatty constituents of tuber- 
cle, and in this way promoting its disintegration ; of this class are 
naphtha or pyro-acetic spirit, oil of turpentine, tar, sulphuric ether, 
and various fixed oils. Xaphtha, which has been so highly recom- 
mended by Dr. Hastings in the treatment of phthisis, has in my hands 
proved serviceable in a very limited number of cases ; but its efficacy 
has seemed to me to be due to its checking profuse purulent secretion, 
and the cough, hectic, and wasting accompanying it; and in this it has 
appeared to me to operate like the balsams, gum resins, and turpen- 
tines, rather than by any specific influence on the tuberculous deposit. 
So, like these, it often acts unfavourably by checking expectoration, 
and excites pain and tightness of the chest, and hard cough, which 
may even end in inflammation or hemorrhage. Its utility is also li- 
mited by its tendency to irritate or disorder the stomach. 

Fixed oils possess a solvent power over the fat of tubercle, and they 
exercise no irritating operation on the living textures : they may there- 
fore be administered in quantities ample enough to justify the expec- 
tation, that some decided influence may be ensured from their thoroughly 
and abundantly pervading the structures of the body. The greater 
number of the fixed oils, however, if taken in any quantity, soon dis- 



TREATMENT. — COD-LIVER OIL. MODE OF OPERATION. 



397 



agree with the stomach, bowels, or liver, causing nausea, inappetency, 
diarrhoea, bilious disorders, and other unpleasant effects, such as have 
been ascribed to excess of fat in food (§ 60.) Such consequences have 
been found to ensue when olive or almond-oil, or cream, has been taken 
for several days. In this respect, as well as its superior utility in the 
system, the cod-liver oil surpasses every other oil ; for it has no purga- 
tive property, and, with proper management, may, in a great majority 
of cases, be made to agree well with the stomach. It is not improba- 
ble that its more easy digestibility in some measure depends on its con- 
taining biliary principles : in many instances it has a marked effect in 
increasing the secretion of the liver ; and if this is sufficiently carried 
off by the several processes of combustion and elimination, no tendency 
to sickness results from its use. It is therefore not surprising that cod- 
liver oil can be administered in larger quantities, and for a longer time 
in cold seasons than in warm ; to persons who can use exercise^ than to 
the sedentary ;. and especially to those in whom the action of the bowels 
is regular and sufficient, than to those subject to costiveness or irre- 
gularity. With many weakly persons it proves of great assistance to 
the digestive function, in promoting a secretion of bile ; and in not a 
few instances I have found it effectual in improving and rendering more 
fluid this secretion in persons liable to gall-stones or obstructions from 
inspissated bile. On the other hand, it is apt to disagree in cases of 
inflammatory dyspepsia, especially that affecting the duodenum; in 
those of hepatic congestion, with fulness and tenderness in the hypo- 
chondria, and in all states of acute inflammation or fever. All such 
affections should be relieved by saline effervescent draughts, mild mer- 
curial aperients, and such means, before the oil is administered : and 
in the case of persons prone to these disorders, the same medicines 
may be frequently required during its use. 

The beneficial operation of cod liver oil extends to almost every func- 
tion and structure of the body. In cases most favourable for its use, 
there is a progressive improvement in digestion, appetite, strength, 
flesh, and complexion; and various morbid conditions diminish in a 
very marked manner. Thus purulent discharges are lessened, ulcers 
assume a healthier aspect, colliquative fluxes cease, the natural secre- 
tions become more copious, and the pulse less frequent. It is difficult 
to comprehend how it can produce such marvellous and manifold salu- 
tary effects ; and it must be admitted that its modes of operation are 
but obscurely understood. Certain properties, however, may be pointed 
out as peculiar to this oil, and these may have some share in contri- 
buting to its remedial powers. Thus it forms an emulsion more readily 
than other oils, and even saponifies with alkaline carbonates ; and this 
circumstance may serve to explain its easier digestibility and absorp- 
tion from the alimentary canal. Probably connected with the same 
property is its containing more or less of the distinctive constituents 
of the bile, the salutary operation of which, on the hepatic function, 
has been already alluded to. Its superior penetrative and suppleing 
property has always rendered cod liver oil most valuable in currying 
leather ; and previously to its introduction into medicine, this was its 
chief commercial use. 



393 



STRUCTURAL DISEASES. 



, — DEPOSITS. TUBERCLES 



Thus we have an oily matter — well borne by tbe stomach, easily 
diffused by emulsion through the alimentary mass, readily absorbed 
by the lacteals, where it contributes to form a rich " molecular base" 
in the chyle ; apt to saponify with the basic salts of the blood, and 
when effused in this fluid throughout the capillaries of the body, ca- 
pable of penetrating to all the textures, and of exercising its solvent 
and softening influence on the solid fats of old deposits, and forming 
abundant molecular nucleoli for the formation of new cells. The oil 
in its highly divisible state supplies and renews this fat in a form and 
mode most conducive to active and healthy nutrition. Its fluidity and 
its divisibility enable it to pervade all the tissues, and to penetrate 
even into imperfectly organized deposits, and so to soften their con- 
crete fatty molecules, and to render permeable and supple their whole 
mass, as to bring them more under the influence of the adjoining living 
parts, through whose circulation either their vitality and nutrition may 
be improved and maintained, or, if capable of such improvement, their 
substance may be gradually dissolved and absorbed away. Such ap- 
pears to me the most probable mode of operation peculiar to cod-liver 
oil, assuredly the most efficacious of all medicinal agents in the treat- 
ment of cacoplastic and aplastic deposits. It is true that it also con- 
tains iodine, bromine, phosphorus, and other peculiar constituents, 
to which its efficacy has been ascribed; but not only is the proportion 
of these constituents too minute to have much influence in determining 
results so prompt and so considerable as those which are often obtained 
from the administration of cod-liver oil, but also it may be objected 
that these several elements have been used in various other combina- 
tions without an approach to such satisfactory results. On the other 
hand, certain other oily matters have in a limited number of cases 
been exhibited with a success more resembling that commonly attend- 
ing the use of the cod-oil. Thus cream, bacon, mutton suet in milk, 
cocoa-nut oil, almond-oil, and neatsfoot-oil, have been found by several 
practitioners to be beneficial in the same manner as the fish oil; and al- 
though the testimony in favour of all these falls far short of that in 
favour of the latter agent, yet it approximates them to it much more 
nearly than any evidence whicb can be brought in favour of iodine, 
bromine, or any other chemical element or combination. 

The present state of our knowledge appears therefore to justify the 
conclusion that cod-liver oil is chiefly beneficial as an oil, supplying a 
material which enriches the blood, affords both combustive and nutri- 
tive elements, and penetrates throughout the tissues and deposits, 
softening their concrete fat, and rendering more supple their solid 
fabric. The superiority of cod-liver oil over other oils seems to con- 
sist in its easier digestibility by the stomach and chylopoietic organs, 
which is probably dependent on the bile, and perhaps other ingredients 
which it contains. The nutrient properties of cod-oil have been proved 
by its increasing the proteinaceous constituents of the blood, (except 
the fibrin, which is diminished,) and Dr. Theophilus Thompson has 
ascertained that the same result has followed the use of the coco: 
oil. (Proceedings of the Royal Society, 1854.) 

The limits of this work prevent me from entering into farther details 



TREATMENT — COD-LIVER OIL. VARIETIES. 



399 



on the use of cod-liver oil in particular diseases ; but with regard to 
pulmonary consumption, after further experience in several thousand 
cases, I do not hesitate to repeat a statement which I published seven 
years ago; — That the pure fresh oil from the liver of the cod is more 
beneficial in the treatment of pulmonary consumption than any other 
agent medicinal, dietetic, or regiminal, that has yet been employed. 
(London Journal of Medicine, Jan., 1849.) The amount of good 
wrought by the oil varies greatly: in some cases being very slight and 
transient; in others, equally decided and lasting; in some, it only les- 
sens and retards the progress of the disease; in others, it arrests it 
and effects a cure more or less permanent. The average duration of 
life in pulmonary consumption was by Laennec and Louis reckoned at 
two years. So far as I have been able to estimate by a hasty calcu- 
lation, this average is prolonged to four years by the aid of the cod- 
liver oil and other means. 

As some difference of opinion seems to exist as to the kind of oil 
that is best for exhibition, it may be well to say a few words on this 
point. The dark-brown cod-liver oil of commerce, which is used by 
curriers, was that employed by Dr. Bardsley in this country fifty years 
ago ; and is still recommended by Dr. Darling, who has prescribed it 
with great success in scrofulous affections during the last thirty years. 

A brown oil of more or less impurity has also been in use as a reme- 
dy, first by the people, and subsequently by the profession, in Holland, 
Germany, Norway, and other northern parts of the Continent, for many 
years past. In 1841 Dr. Hughes Bennett published a work on the oil, re- 
commending its use on the authority of several continental practitioners, 
and giving preference to a light-brown oil. At this date I began to 
prescribe this oil; but I found so much objection on the part of pa- 
tients, and sometimes such real disorder produced by attempts to take 
it, that I came to the conclusion that, however Dutch and German 
stomachs might bear it, English ones could not, at least among the up- 
per classes. It was not until the pure pale oil was brought under my 
notice, that the difficulties in administering it gave way ; and during 
the last ten years, I have prescribed it for nearly nine thousand pa- 
tients, and with such success that it was taken without material diffi- 
culty by ninety-five per cent, of the whole number ; and of those who 
thus took it, fully eighty-five per cent, derived more or less benefit 
from its use. This experience, which is in accordance with that of 
many of my professional friends, is at least quite as strong as any 
that can be adduced in favour of the brown or impure kinds of oil ; 
and it does seem absurd to recommend the exhibition of the remedy in 
its offensive form, when the pure fresh oil has been proved to be at least 
equally efficacious. 

The dark-coloured and strong-smelling oils owe their offensive pro- 
perties to the partial decomposition and putrefaction which the livers 
undergo before and during the process of separating the oil from them. 

They thus acquire a strong fishy smell and taste, like that of lamp- 
oil, which, although highly disgusting to most persons, are not disliked 
by a few who resemble Bussians and Laplanders in their tastes. Dr. 
L)e Jongh, who has given the sanction of his name to an article widely 



400 



STRUCTURAL DISEASES. — DEPOSITS. — TUBERCLE. 



advertised in this country in the last few years, strenuously advocates 
the superiority of the light-brown oil ; but, as Dr. Garrod has well 
shown (Brit, and For. Med.-Chir. Rev., Jan., 1856,) the facts which he 
adduces by no means bear out his assertions ; and the general results 
of chemical analysis, as well as of clinical experience, are altogether 
in favour of the pure pale oil as carefully prepared in this country and 
in Newfoundland. The process is thus described by Dr. Garrod: — 
"The livers are collected daily, so that no trace of decomposition may 
have occurred ; carefully examined, in order to remove all traces of 
blood and impurity, and to separate any inferior livers : they are then 
sliced, and exposed to a temperature not exceeding 180° Fahr., till 
all the oil has drained from them. This is filtered, afterwards exposed 
to a temperature of about 50° Fahr., in order to congeal the bulk of 
the margarine, and again filtered 1 and put into bottles well secured 
from the action of the air.' 7 (Brit, and For. Med.-Chir. Rev., Jany., 
1856.) In fact, the great object to be kept in view in the preparation 
of the oil, is to separate its more liquid part in the simplest and speediest 
manner from all contaminating matters, so that it may be administered 
in the pure state in which it exists in the cells of the liver of the living 
or recently dead fish. Much meddling or tedious elaboration will in- 
jure it as much as carelessness or roughness of preparation; for ex- 
posure to the air soon turns it rancid and spoils its freshness as if it 
remained in the livers until they became stale. The sweetest cod-oil, 
if rubbed on the skin, acquires a very offensive smell in the course of 
a few minutes; hence the stench produced by the practice of rubbing 
the oil on the surface of the body is so sickening as to render this mode 
of exhibition intolerable with many individuals. If inunction should 
prove to be as serviceable as stated by Professor Simpson, it would be 
much better to use almond or olive-oil rather than cod-oil; for I feel 
sure that, among the upper classes at least, it would soon bring the 
latter into disgrace, to attempt to administer it in a mode which ren- 
ders it truly disgusting. 

When we consider the amount and variety of beneficial effects which 
result from the use of cod-liver oil, and that its exhibition ought to be 
continued not for days and weeks only, but for months and years, we 
shall perceive the vital importance of obviating as much as possible all 
objections of taste, smell, nauseousness, and other causes of offensive- 
ness, to the senses, stomach, or system, which may impede its continued 
administration. I will therefore add a few directions as to the parti- 
culars of its exhibition. * 

(1.) The Oil. — It should be as fresh, and as free from taste and 
smell, as it can be procured. Several of the leading chemists in Lon- 
don (Messrs. Bell, Squire, Taylor, Allen, Savory, Curtis, Fincham, 
and others) prepare during the winter season, an oil, which, for sweet- 
ness and freshness, surpasses any obtained from abroad; and from De- 
cember to the end of June I have found the London-made oil gene- 

1 1 have always recommended the oil •without the solid margarine and stearine, both 
from the experience that it agrees better with the stomach, and from the views which I 
entertain as to its mode of action. Dr. Garrod has tried the solid residuum of the oil, 
and found that the few patients who were able to take it derived no advantage from its use. 



TREATMENT. — COD-LIVER OIL. DIRECTIONS FOR ITS USE. 401 



rally prove the best. Soon after midsummer, a supply is imported from 
Newfoundland, and that prepared there with great care by Mr. Fox is 
generally excellent, being at this season quite equal to the home-made 
oil, with the recommendation of being considerably cheaper. 1 The oil 
should be kept in a cool place, in moderate-sized bottles, well corked, 
and not opened or exposed to the air more than is necessary. 

(2.) Mode of Exhibition. — Many persons, especially children, can 
take the oil alone without any difficulty : and in such a case it seems 
needless to recommend any adjunct. Yet even with these, if the re- 
medy is to be continued for a long time, it is better to give some agree- 
ably-flavoured tonic with it, for this prevents the palate and stomach 
from being palled by repetition, which is very apt to occur when the 
oil is long taken alone, however well borne and even relished at first. 
To the great majority of patients it is more agreeable to disguise the 
taste of the oil ; and this may be done by giving it in another liquid 
which may also act as an agreeable tonic to the stomach. Some che- 
mists have endeavoured to render the oil more palatable by the addition 
of an essential oil or other flavouring matter; but, according to my ex- 
perience, this does not fully disguise the taste or smell, and it increases 
the tendency to unpleasant eructation afterwards. The best way is to 
take the oil floating on a well-flavoured tonic, such as the compound 
infusion of orange-peel, with the addition of a little diluted nitric and 
hydrocyanic acids, and either sweetened with syrup, or rendered more 
bitter by the addition of a little tincture of hop or calumbo, according 
to the fancy of the palate or the requirements of the stomach. The 
bulk of the whole dose should be small, so that it may be swallowed 
at a single draught ; therefore the quantity of the vehicle should not 
exceed a tablespoonful, or half an ounce, with a teaspoonful of oil, 
which is to be gradually increased to a tablespoonful. The dose of oil 
should rarely exceed a tablespoonful twice or three times a day : when 
a larger amount is taken at a time, it generally either deranges the 
stomach or liver, or some of it passes unabsorbed by the bowels. The 
diluted sulphuric, phosphoric, or nitro-muriatic acid may be substituted 
for the nitric in the vehicle, and form agreeable varieties, better suited 
in some cases ; but as a general rule, I have found the nitric acid the 
best, as tending more to correct the richness of the oil, and causing 
less tendency to lithic deposits in the urine. The chief advantage of 
exhibiting the oil in such a tonic as that now recommended, is that, 
in addition to disguising the taste of the oil, the tone of the stomach 
is also kept up, so that it bears the oil in full doses and for a long 
period: and in this respect it is superior to orange or ginger wine, aro- 
matic waters, coffee, milk, and other vehicles that are occasionally used. 
In cases of peculiar weakness of stomach, with tendency to nausea, I 
have often given a fortieth or a thirtieth of a grain of strychnine in 
solution with each dose with great success. Infants and young chil- 
dren generally take the oil without difficulty ; and it is easy to disguise 
it in a very palatable and attractive form, in an emulsion with mucilage 
or the yolk of an egg, and a flavoured syrup. 

1 A good pale oil lias also been recently imported from Norway, of a quality muck 
superior to that sold as Dr. De Jongh's oil. 

26 



402 



STRUCTURAL DISEASES. — DEPOSITS. TUBERCLE. 



(3.) Time of Exhibition: Diet, — General experience has proved 
that the oil agrees best when taken during or shortly after a meal. For- 
merly I recommended it to be taken from one to two hours after; but 
I have lately found that it rises less, and leaves the appetite more free 
for the next meal, if swallowed ten or fifteen minutes only after the 
meal. When taken on an empty stomach, it often causes eructations, 
with a rancid, unpleasant taste of the oil for hours. In most instances 
after the first two or three meals is the best time, as the stomach is, 
with the body, more fatigued towards the close of the day ; but I have 
known several persons to take it well at bed-time ; these are generally 
good sleepers, whose sound repose hides any symptoms of disagreement. 

With some individuals the oil agrees so well, and so much improves 
their digestive powers, that they require little or no restrictions in 
diet; but this is not the case with the majority. The richness of the 
oil does prove more or less a trial, sooner or later, to most persons ; 
and to diminish this trial as much as possible, it obviously becomes 
proper to omit or reduce all other rich and greasy articles of diet. All 
pastry, fat meat, rich stuffing, and the like, should be avoided, and 
great moderation observed in the use of butter, cream, and very sweet 
things. Even milk in any quantity is not generally borne well during 
a course of oil ; and many find malt liquor too heavy, increasing the 
tendency to bilious attacks. A plain nutritious diet of bread, fresh 
meat, poultry or game, with a fair proportion of vegetables and a little 
fruit, and a moderate quantity of liquid at the earlier meals, commonly 
agrees best, and facilitates the exhibition of the oil in doses sufficient 
to produce its salutary influence in the system. 

But no remedy, however beneficial, should lead to the neglect of 
those general and hygienic measures by which the constitutional health 
may be promoted and sustained ; or, in other words, by which the great 
functions of circulation, respiration, digestion, absorption, and excre- 
tion, may be kept at the healthy standard. Mention has so often been 
made of these measures, that it would be superfluous to particularize 
them again ; but it may not be inexpedient, in concluding this subject, 
to allude once more to such of them as promote the absorption of caco- 
plastic and aplastic deposits. 

That such absorption is a possible event, is indisputably proved by 
the changes that these deposits undergo in chemical composition, as 
well as in physical condition, in process of time (§ 556, 561.) The 
most salutary of these changes are quickened, and the removal of the 
most injurious portion of the deposit is brought about, by maintaining 
as free and active a circulation through and near the affected part as 
can be carried on without inducing irritation or hyperemia. Hence 
the utility of regular exercise, of frequent friction of the surface in the 
vicinity of the seat of the mischief, and of rubefacient applications or 
salt water aspersions. The more vigorous circulation thus excited, pro- 
motes the gradual solution of the deposits, chiefly by the oxidating in- 
fluence of the current of arterial blood that is thrown with more force 
through the neighbourhood. This probability naturally suggests the 
inquiry whether it is possible to aid this process by oxygenating the 
Mood more highly than can be done merely by the free respiration of 
pure air? I have already suggested that it is probable that such 



CLASSIFICATION OF GROWTHS. — NON-MALIGNANT. 



403 



agents as nitric and nitromuriatic acid and chlorate of potass, may con- 
tribute to this object; and I now again allude to this, because I have 
found their continued use beneficial in many cases, after inflammation, 
when circulation and absorption were slack, and cacoplastic effusions 
were accumulating and threatening farther mischief. These oxyge- 
nating medicines also sometimes produce decided improvement in the 
general and local symptoms of scrofulous and tubercular disease during 
the maturation and softening of their deposits. Their utility is how- 
ever limited by their tendency to irritate the alimentary canal when 
they are given largely or continued long; but they may commonly be 
advantageously used during the intervals, w T hen courses of cod liver oil, 
of iron, and of other tonics are temporarily interrupted. 



SECTION VII. 

MORBID GROWTHS. 

569. Under the term morbid growths or tumours may be arranged 
certain structures which are developed in the animal body in addition 
to the natural textures. They differ from hypertrophy and from eu- 
plastic deposits, in the peculiarity of their structure ; and from caco- 
plastic and aplastic deposits, in their higher degree of organization. 
In other words, they are distinguished from hypertrophy, and euplastic 
formations, by the kind of their vitality ; and from degenerations and 
cacoplastic deposits, by the degree of their vitality. They are, in fact, 
new structures ; and although some of them in general characters, and 
most of them in elementary composition, resemble normal textures of 
the body ; and although all derive their nourishment from the blood ; 
yet, in their origin, and mode of growth, they are more essentially dis- 
tinct from the natural structures than are any of the results of diseased 
nutrition hitherto considered. For these reasons, they have been termed 
new and parasitical growths ; and the latter term is the more applica- 
ble to them, because their existence and method of increase cannot 
generally be traced to such variations in the local circulation as are 
found to be chiefly concerned in producing and influencing the modifica- 
tions of nutrition hitherto noticed. 

Morbid growths have been divided, for distinction's sake, into ana- 
logous, or those whose structure somewhat resembles some natural tex- 
ture (including false membranes, &c. ;) and non- analogous, or heterolo- 
gous, those which have no parallel in the healthy state of the animal 
economy. But this classification is inconvenient, because it is also ap- 
plied to the products of diseased nutrition that are arranged as another 
group (hypertrophy and deposits:) and it is often inapplicable, inas- 
much as many morbid growths are essentially compound, comprising 
some forms that resemble natural textures, and others that do not; all 
being, nevertheless, composed of similar elementary molecules; this is 
especially the case with carcinoma. 

The classification into non-malignant and malignant, here adopted, 
is therefore more useful in a practical point of view, although it may 
not be easy to make it precisely applicable to ail cases. 



404 



STRUCTURAL DISEASES. — GROWTHS. 



SECTION VIII. 
NON-MALIGNANT GROWTHS. 

570. The term non-malignant properly belongs to those growths or 
tumours which have their seat in one part of the body, without any 
tendency to produce similar formations in other parts; and which 
arise among, but do not invade or penetrate, the natural structures ; 
and, if they prove injurious, it is by their bulk or position, or by the 
extent to which they abstract nourishment from the rest of the body. 

571. The most simple of the morbid growths are serous cysts, which 
consist of a shut sac, "containing serum, and formed of condensed 
cellular substance resembling serous membranes, which are formed gra- 
dually around a clot of blood, or any foreign substance in the system ; 
and are frequently developed spontaneously in various parts of the 
body. They are frequently attached to the natural serous membranes, 
but sometimes quite separate from these ; sometimes solitary, sometimes 
set together in clusters ; and their size and shape are very various. 
They must be distinguished from enlargements of natural cavities, such 
as the calices of the kidneys, or Graafian vesicles in the ovaries. They 
are often unconnected with disease of the adjacent textures; but in 
some cases, these textures are found either wasted by absorption" 
(atrophy from pressure, § 532,) " or disorganized by inflammation around 
them. There is no evidence of their being generally connected, in 
their commencement, with inflammatory action; and when they are 
small, their existence is often not denoted by any symptoms t whatever." 4 - 

Besides the exceptions alluded to above, there are several other cases 
of apparent tumours which do not really belong to this class of forma- 
tions, but are rather results of hypertrophy, dilatation, or unusual de- 
velopment of a natural structure, and therefore must be referred to a 
previous paragraph (§ 528.) The enlarged bursse, occurring in situa- 
tions subjected to pressure; the dilated mucous follicles of the cervix 
uteri ; the cutaneous follicular distention from fatty or other matter 
which constitutes subcutaneous adipoma and melliceris; the obstruc- 
tion of, and concretion within, the salivary ducts known as ranula, are 
all of this kind. I am also inclined, with Dr. Hodgkin, to extend the 
same remarks to the small serous cysts frequently found in the kidneys 
and liver, which I have before described as portions of secretory ducts 
obstructed and distended with serum, (p. 223, note.) It may be fairly 
questioned, too, whether some serous cysts are not simply due to enormous 
enlargement of the primitive or compound cells of which many textures 
are partly composed. Dr. Hodgkin has ably advocated an opinion of this 
kind, and has applied the same principle to explain the production of 
more solid and complex growths, by the formation, multiplication, and 
compression of a series of cells. 2 

1 Alison's " Outlines of Pathology," p. 231. 

2 Med.-Chir, Trans., vol. xv., part 2. 



NON-MALIGNANT. — CYSTS. 



405 



572. Cysts, somewhat resembling those above described, are, how- 
ever, sometimes found filled with different unorganized contents, and 
they then constitute the simplest kind of encysted tumours; these form 
in various parts of the body that have a cellular structure, and they 
have received names descriptive of their contents : thus they are called 
— hygroma, when they contain a nearly serous fluid, and form encysted 
dropsy if they attain a large size; hsematoma, when their contents are 
bloody; steatoma, or lipoma, when they are of a fatty nature; and 
atheroma, when made up of an opaque pulpy matter of plaster-like 
appearance. 1 

These cysts are probably often in the first instance formed of ex- 
travasated blood or fibrinous matter, whose exterior becomes organized 
into a sac, the inner surface of which, according to Vogel, secretes an 
epithelium; whilst the interior is more or less removed, and either re- 
placed by serum, which may be thickened by epithelium scales, or con- 
verted into fatty, or even osseous matter in tJfe same manner as aplastic 
deposits (§ 561,) and the contents of old abscesses. 2 When such tu- 
mours form under the skin, they often contain epidermis scales, which 
either render the fluid opaque and thick, or agglutinate with it into a 
horny solid. If in the vicinity of hairy parts they occasionally have hair 
in them. In some instances cholesterin has been found in them in great 
abundance; and this not only in cysts connected with the liver, but 
also in the large and often compound, cystiform tumours connected 
with the ovaries. Cysts in these last organs have been known to en- 
close perfectly formed teeth and bones as well as hair. 

573. Complex cystiform tumours are more varied in their structure, 
and exhibit farther deviations from normal organization. They chiefly 
occur in connexion with glandular organs or such as naturally possess 
cysts or vesicles, as, for instance, the ovaries. 

A still more complex kind of tumour is that which is generally de- 
signated by the term sarcomatous ; this consists of solid matter more 
or less organized, and mostly bearing a resemblance to one or more 
structures naturally existing in the body, and especially in the part in 
which the tumour grows. Thus there are ; — fibrous tumours, consist- 
ing of densely compacted fibres, scantily supplied with blood-vessels, 
generally slow in growth, and, like fibrous deposits, liable to ossifica- 
tion ; — Steatoma or adipose sarcoma, resembling natural adipose tex- 
ture, but often rendered more dense by combination with some fibrous 
structure; — Chondroma, or cartilaginous tumour, forming rounded 
masses that have a considerable analogy with cartilage, but that are also 
apt to be mixed with bands of fibrous texture, and are liable to ossifi- 
cation ; — Vascular tumours, [Hsematoma, erectile tumours,) consisting 
of a congeries of blood-vessels of considerable size, apparently enlarged 
capillaries, with more or less connecting filamentous tissue. These last 

1 For examples of cysts of different kinds, see Pathological Trans., vol. vi., pp. 8, 12, 
335; and for a further description, see Mr. Paget' s "Lectures on Surgical Pathology," 
Vol. II. 

2 Vogel suggests that cysts, with various contents, may originate in old abscesses 
which have never opened, and whose pus has gradually undergone transformation. Cysts 
in the liver, filled with a gelatinous, and in some instances a putty-like matter, and com- 
monly passing for tubercle, are most probably produced in this way. 



406 



STRUCTURAL DISEASES. — GROWTHS. 



are greatly modified according to the freedom with which they com- 
municate with arteries : when supplied by large arteries they are florid 
in colour; they pulsate; and if large, the pulsation is attended by a 
blowing or rasping sound such as is heard in vascular bronchocele: 
when the arterial communication is not free, the tumours exhibit the 
darker hue of venous blood. 1 

Dr. Hodgkin considers that the complex cystiform tumour, such as 
occurs in the ovary, is a type of the mode in which morbid growths 
originate in general, not excepting those of a malignant kind. From 
the internal walls of one original or parent cyst, there spring a number 
of other cysts, containing different kinds of matter, and as these grow, 
they fill the original cyst, and project beyond it, other cysts being pro- 
duced within them; in this way an extension of substance takes place, 
subject to modifications from the nature of the texture in which it 
occurs, as well as from that of the contents of the cysts. In solid 
structures, like dense cellular membrane, the cysts are so compressed 
as to present the appearance of fibres radiating from a centre, and lose 
all their liquid contents. Sometimes the adjoining textures, as well as 
the walls of the cavities, inflame and cohere, and so obliterate the cys- 
tiform character of the tumour. 

574. The pathological cause of morbid growths is involved in much 
obscurity. At present nothing farther can be surmised than that these 
arise from alteration of the vital properties of some of the molecules of 
the textures in which they are developed ; so that, instead of being 
assimilated to the textures, and conforming to the ordinary laws of 
their growth and decay, these molecules spring into existence and 
attach themselves together in modes more or less peculiar, and behave 
themselves more or less independently of the influences of the adjoin- 
ing living parts. Where these modes are the least peculiar and the 
most dependent on the nutrition of the adjacent structures the growths 
are the least abnormal, vary the least from these structures in their 
origin and course, more resemble either hypertrophy (§ 525) or euplas- 
tic deposits (§ 547,) and do mischief rather by their size or situation 
than from their intrinsic nature. Where the mode of growth is the 
most peculiar, and where it is the most independent of that of the ad- 
joining textures, the resulting tumours are the most abnormal in their 
nature and mode of development ; and approach most in character to 
malignant disease, operating injuriously, not only by their . bulk and 
position, and by their abstraction of the nourishment of the body, but 
also by their tendency to encroach upon and supersede natural struc- 
tures, and to contaminate distant parts through the blood. 

575. Near the outer boundaries of the group of non-malignant 
growths, may be placed those peculiar bodies, called hydatids or ace- 
phalocvsts. These are unlike all other morbid productions of the class, 
both in the matter of structure and contents, and they are quite de- 
tached from the textures in which they occur. It may therefore be 
inferred that they possess an entirely independent vitality. This, al- 

1 For further details respecting the pathological character of tumours, the reader is 
referred to Rokitansky's Pathological Anatomy, Paget' s Lectures on Surgical Pathology, 
and the Transactions of the Pathological Society of London. 



KON-MALIGNANT. — HYDATIDS. 



407 



though of a low degree, is indisputable, and is exhibited, (1.) in their 
power of self-nutrition, expressed by their progressive increase in size, 
and by the peculiar nature of their walls, which are much more elastic 
than any normal animal texture; (2.) in their power of secretion, mani- 
fested by the presence within their cavities of a limpid and colourless 
liquid, which is constant in its character, whatever be the nature of the 
matter in the serous cyst that separates them from the ordinary tex- 
tures of the frame ; (3.) in their power of reproduction by gemmation, 
the young gemmule being developed in the membranes of the parent 
cyst, and thrown off either internally or externally according to what 
the species may be. Professor Owen 1 describes the hydatid as "an 
organized being, consisting of a globular bag, which is composed of 
condensed albuminous matter, of a laminated texture, and containing 
a limpid colourless fluid, with a little albuminous, and a greater pro- 
portion of gelatinous substance." He adds, "As the best observers 
agree in stating that the acephalocyst is impassive under the applica- 
tion of stimuli of any kind, and manifests no contractile power, either 
partial or general, save such as evidently results from elasticity — in 
short neither feels nor moves — it cannot, as the animal kingdom is at 
present characterized, be referred to that division of organic nature. 
It would then be a question, how far its chemical composition forbids 
us to rank the acephalocyst among vegetables. In this kingdom it 
would obviously take place next those simple and minute vesicles which, 
in the aggregate, constitute the green matter of Priestley, (Protococcus 
viridis, Agardh;) or those equally simple but different coloured psy- 
chodiarise, which give rise to the red snow of the arctic regions, (pro- 
tococcus kermesianus.) These, first-born of Flora, consist, in fact, of a 
simple transparent cyst, and propagate their kind by gemmules de- 
veloped from the external surface of their parent." 

The researches of Schleiden, Schwann, and their followers, have 
thrown some light on the probable origin of hydatids, by showing that 
the primitive cells of animal, as well as of vegetable structure, are to 
a great extent like hydatids in their anatomical composition, growth, 
and mode of reproduction; for the hydatid appears to be a cell, in the 
interior of which are developed nuclei and nucleoli, the germs of young 
cells. But if it be presumed, on this account, that hydatids are really 
offsets of living structures of a high order in the scale of development, 
and capable of living apart from the general mass of the body, it still 
remains a mystery how this divided or detached life can be thus ac- 
quired by certain molecules on rare occasions, contrary to the usual 
law. The imagination may conceive, perhaps, that there is some ana- 
logy between hydatids and the polype tribe of animals, which can be 
indefinitely propagated by division ; and that the conditions of the body, 
in which hydatids are produced, reduce the plasma of certain parts to 
the standard of this grade of life; but such conception does not soften 
the difficulty much, and indeed must be held to be too exclusively a 
speculative matter to be dwelt on here. 

576. The situations in which hydatids have been most commonly 

1 "Cyclopaedia of Anatomy," &c, article Eniozoa. 



408 



STRUCTURAL DISEASES. — GROWTHS. 



found are the liver, the lungs, the spleen, the kidneys, and the ovaries. 
M. Andral records an instance in which he found hydatids in the blood 
within the pulmonary veins; and there was also a large cyst full of 
hydatids in the liver. 1 The condition of the system in which they have 
been most frequently found to occur is that of cachexia and mal-nu- 
trition. They are usually contained in a serous or protective cyst 
(§ 571) formed by the surrounding texture; and the symptoms which 
they occasion are merely such as are necessarily caused by their bulk 
and position, making them compress, displace, and irritate organs, and 
causing atrophy and inflammation in their textures. In the containing 
cyst there is commonly observed more or less of opaque laminated 
matter, which appears to be the debris of collapsed hydatids; indeed, 
some that retain the globular form exhibit the commencement of decay, 
in an opacity and wrinkling of their walls, and in the changed colour 
of their contents. But I have likewise had frequent occasion to notice 
a considerable quantity of opaque, yellowish pultaceous matter mixed 
with the collapsed hydatids, and lining the containing cyst: this, under 
the microscope, appeared to consist of granular matter and imperfect 
cells mingled with much fat, and in one instance, where the hydatid 
sac lay between the liver and the diaphragm, there were abundant 
crystals of cholesterin : I have therefore been led to regard this opaque 
matter as a deposit from the surface of the sac, subsequently degene- 
rated into aplastic and fatty substance. 

577. The echinococcus is a variety of hydatid, which differs from 
the form alluded to above chiefly in its having a yellowish and tougher 
outer tunic, and in its containing distinct animalcules within it, (yermi- 
culi echinococci.) It has been found in the liver, spleen, mesentery, and 
substance of the heart, and upon rare occasions in the urine. The cysti- 
cercus occurs in muscular structure, and in one instance was seen in 
the aqueous humour of the eye. It has a distinct structure, consisting 
of a cystiform body, and a head provided with suckers and hook-like 
processes, by which it attaches itself. The distoma fiepaticum, or, 
liver-fluke, is rarely observed in the human subject. It is the sup- 
posed cause of the rot in sheep, and was observed by Andral and De- 
lafond chiefly in those animals in which dropsy was present, and in 
whose blood there was a defect of albumen (§ 222.) The rot chiefly 
attacks sheep fed in wet clayey pastures. 

The subject of intestinal worms belongs to special pathology. 

578. There is but little to be said regarding the medical treatment 
of morbid growths. To such kinds as approach most nearly in charac- 
ter to the natural textures, the observations that have been made on 
hypertrophy (§ 529) and euplastic deposits (§ 552) apply. So far as 
they originate from, or are augmented by, local determination of blood, 
or any other kind of hyperaemia, the remedies for those states may be 
looked to for the retardation of their development. But as their espe- 
cial peculiarity is an alteration of the vital properties of the primi- 

1 For examples of Hydatids, see Pathological Transactions — in the Pericardium, vol. 
vi., p. 108; in the Peritoneum, vol. v., p. 303; in Cellular Tissue, vol. v., p. 298; passed 
by the Urethra, vol. v., p. 298, &c. 



NON-MALIGNANT. — HYDATIDS. 



409 



tive molecules of textures, little is to be expected from measures which 
act. only on the quantity of the nutritive material. Indeed, in many 
instances, morbid growths seem to originate in connexion with a de- 
pressed rather than with an exalted condition of the vascular func- 
tions ; and in such as are most like to parasites in nature, the general 
or constitutional powers are weakened in proportion to their develop- 
ment. Hence, the treatment indicated as appropriate for such cases 
is one of a supporting and tonic kind, with due regard to the regula- 
tion of digestion and secretion. This, however, requires modification 
when the morbid growths mechanically excite a considerable amount of 
inflammation, or even of local obstruction to the circulation. 

We are not acquainted with any medical means whereby the altera- 
tions of vital properties in the molecules from which morbid growths 
take their rise, can be corrected. The same spontaneous power which 
places these growths beyond the controlling influence of the laws of 
textural nutrition, removes them also beyond the reach of general reme- 
dies. The surgeon can in some instances remove the part by the knife, 
and he can sometimes further modify the abnormal state by the direct 
application of escharotics or caustics, which are capable of destroying 
the morbid cells or germs which are the roots of the growth; and 
when this can be effectually done without serious injury to vital organs, 
the cure may be complete. Mechanical pressure carefully and steadily 
applied in such a way that it diminishes the supply of blood to the tu- 
mour without interrupting the circulation in other parts, has sometimes 
been efficacious in restraining the increase, and even in promoting 
the absorption of morbid growths. It is doubtful whether the physi- 
cian possesses the power to aid the surgeon in these cases, or to control 
the development of the mischief when it is beyond the reach of the sur- 
geon's art, further than by promoting the general health of the frame. 

In many instances, the secondary pathological changes induced by 
morbid growths, such as inflammation, congestion, dropsy, and flux, 
become the chief objects of treatment, and much benefit may then fol- 
low the employment of the usual remedies; this benefit is, however, 
commonly limited, both in extent and time, by the persistence and in- 
tractability of the structural change that holds the position of cause. 
Thus where there is encysted dropsy of the ovarium, the accompanying 
peritonitis, ascites, oedema, obstruction of the intestines, and other se- 
condary functional disturbances, generally admit of relief for a time ; 
but as the ovarian tumour remains, and too often increases in spite of 
all treatment, these disorders recur again and again, and at last prove 
fatal. But the growth of the cysts themselves, although generally 
progressive, is occasionally very capricious — sometimes it is very rapid ; 
in other instances, even under apparently the same circumstances, it 
remains stationary for many years. Nay, cases have occurred, although 
but rarely, where encysted tumours have altogether disappeared : par- 
ticularly after the operation of tapping, or after spontaneous rupture 
into some of the cavities of the body. But such instances, although 
establishing a possibility that bears upon both prognosis and treatment, 
are nevertheless to be considered rather as exceptions to the rule that 
is more generally observed. There is more promise of success in the 



410 



STRUCTURAL DISEASES. — GROWTHS. 



results already obtained from the practice of injecting ovarian cysts with 
a solution of iodine, which, even when used of considerable strength, 
causes very little irritation, and yet modifies the secretion and nutrition 
of the cyst. 



SECTION IX. 
MALIGNANT GROWTHS. 

579. Malignant growths are distinctly organized structures, that 
appear in various situations in the body, and intrude their own parti- 
cular substance upon the natural textures, often presenting themselves 
successively or simultaneously in different parts. There is perhaps no 
one character that is more indicative of malignancy than a tendency 
to pervade and penetrate the several constituent textures of a com- 
pound organ, and even to form attachments to neighbouring ones, so 
that all are united into one morbid mass: in this respect malignant 
growths are directly contrasted with non-malignant tumours and de- 
posits, which push aside, compress, or distend the adjacent structures, 
but never penetrate into them. Malignant growths thus prove inju- 
rious, and eventually fatal, not merely by their bulk and position 
(§ 569,) but also by the structural change which they induce in vital 
organs: by the intractable ulcerations and fungous sores to which they 
lead; and lastly, by the wasting they produce, and by the deleterious 
influence they exert over the entire functions of the frame. In all 
these points, malignant growths exhibit a character that is perfectly 
distinct from that of the more simple, harmless growths, hitherto de- 
scribed ; but it must be observed, that the degree of malignancy varies 
very much in different cases, one or more of the specified characteris- 
tics being absent, or but imperfectly developed ; and that consequently, 
morbid growths or tumours are occasionally met with, holding a sort 
of uncertain and intermediate position between the non-malignant and 
the malignant. 

580. The names cancer and carcinoma (conferred in consequence of 
a fancied resemblance of the diseased structure to the form of a crab, 
cancer, xapxwos, — which suggests the apt image of numerous claws pene- 
trating and attacking adjacent parts,) have been long applied to the 
whole genus of malignant growths, comprising the following specific 
varieties: — Scirrlius ; mammary pancreatic, and solanoid sarcoma ; en- 
cephaloid or medullary sarcoma ; fungus hsematodes ; colloid or gela- 
tinous and epithelial cancer. That these are all really but modifica- 
tions of the same disease may be inferred from the fact, that they more 
or less resemble each other in the general characters of malignancy 
alluded to above; and that they frequently occur in the same subject, 
either simultaneously in different parts, or successively in the same 
part. Thus persons who have long been affected with scirrhus of the 
breast, often die with medullary sarcoma in the liver or lungs ; or after 
a scirrhous tumour has been removed from some external part, an en- 
cephaloid or fungous affection is developed in its place. The diversi- 



MALIGNANT. — VARIETIES OF CANCER. 411 

ties may, for the most part, be traced to different degrees of activity 
in the specific or cancerous matter, which is the materies morbz, and to 
the varied effects which this matter produces in the implicated textures, 
accordingly as it is more or less intense and energetic. Of all these 
varied forms, it may be said generally, that scirrhus, and perhaps the 
mammary and pancreatic sarcoma, exhibit the most chronic character, 
and the least activity and tendency to increase locally, or to spread 
through the system; whilst the rest (except the epithelial) are more 
acute, cause more rapid growth in the parts first affected, and appear 
more speedily in other parts of the body. 

581. The matter of cancer has a distinct and peculiar structure; it 
consists of nucleated cells and molecules, contained within an areolar 
or fibrous web of very uncertain density. Of these constituents the 
cells must be considered the most important; although they vary some- 
what in form, they are present in every modification of cancerous 
growth. They are generally globular, and retain that shape through- 
out in the soft gelatinous affection ; but in other varieties, some of them 
are caudate or spindle-shaped, as if they were about to be transformed 
into fibres. In scirrhus, and other more solid and chronic forms of 
cancer, the fibrous constituent of the structure is more abundant, so 
that it is even perceptible to the naked eye, as glistening strise or bands 
of cartilaginous hardness, radiating through the mass ; the cancer cells, 
and numerous granules, are seen between these fibres, and accompany 
them to their outermost extremities. In the cerebriform or medullary 
kind of cancer, the nucleated vesicles are in great numbers: and they 
are contained in cellular substance, which is well supplied with vessels. 
This is the variety in which the growth is most rapid, and in which 
sometimes a bloody tinge is given to parts, in consequence of the ex- 
travasation of blood in the loose new texture, whence the name fungus 
Jicematodes. 

582. The intrinsic disposition to grow, often at the expense of nu- 
triment that should be given to other parts of the body, which has been 
mentioned as a property of some formations not distinctly malignant 
(§ 574,) is exhibited in a much more marked degree in malignant struc- 
tures, the increase of which may take place most rapidly when all the 
natural textures are wasting away. This fact, again, suggests the 
idea of there being an independent vitality in these morbid growths, 
in virtue of which, parasitic-like, they flourish luxuriantly, to the de- 
triment of the rest of the frame. The question hence naturally arises, 
— Are these growths truly parasites, developed from ova or seeds in- 
troduced into the body from without, and, after entering it, and find- 
ing a proper nidus or soil, taking root or maturing as distinct organisms, 
after the manner of worms or hydatids, and drawing their nourishment 
from the surrounding fluids and solids? If it be objected to this, that 
malignant growths are too closely attached to, and too much identified 
with, the natural textures of the body to permit the notion to be en- 
tertained that they have a distinctness of being, it may be replied, that 
the cancer cells, their most characteristic portion, are often loose and 
unattached: these propagate themselves by the production of young 
cells in their interior cavities, and by means of these cell-broods are 



412 



STRUCTURAL DISEASES. — GROWTHS. 



disseminated, first in contiguous parts, to which they appear to attach 
themselves ; and subsequently, through the general channels of the cir- 
culation, which, in extensive forms of the disease, have been found to 
contain cancerous masses. An experiment made by Professor Langen- 
beck was supposed to have proved that cancerous pulp containing cells 
is capable of communicating the disease to animals on being injected 
into their veins, but the attempt to effect this purpose has since been 
frequently made by other pathologists without a like result. If such 
an experiment could be made to succeed, it would cause cancer to rank 
with contagious disorders, such as have been already named as having 
a possible connexion with parasitic origin (§ 99.) Contagion is not, 
however, a common cause of cancer; the only unquestionable example 
ever adduced to prove it so, being the rare one of the penis having been 
infected by a carcinomatous os uteri. It has also been pertinently re- 
marked, by Dr. W. Budd, 1 that the causes which seem to be most in- 
fluential in inducing cancer are not such as can, in any intelligible way, 
favour the introduction of germs from without the body. Thus, in 
chimney-sweeps and others, the continued application of soot has been 
observed to be followed by the occurrence of cancer in the scrotum in 
so many cases, as to justify the inference that it was the exciting cause 
of the mischief. The often-repeated contact of a tobacco-pipe with the 
lip has also been frequently the precursor of cancer in that part. 

The only alternative that remains is the assumption already stated 
— that cancer arises from a peculiar perversion of the natural nutritive 
process, in some degree analogous to such as has been already referred 
to when alluding to other kinds of morbid growth ; but in the case of 
the malignant disease, the perversion is much greater in degree, and 
shows itself such not only in the origin, but also in the whole history 
of the affection. It can easily be conceived that causes acting for a 
long time locally, as, for instance, the application of soot to the scro- 
tum of chimney-sweepers, of the tobacco-pipe to the lips of inveterate 
smokers, of irritations to the stomach in habitual dyspepsia, and to the 
uterus in irregular menstruation, may induce this extraordinary altera- 
tion in the molecular nutrition of these parts ; but the peculiarity of 
the alteration is by no means explained by the conception. In other 
words, if it is assumed that cancer cells are modifications of the natu- 
ral cell germs out of which textures are produced, the anomaly of the 
independent vital properties and growth of these modified cells, ob- 
viously so different from those of texture cells in general, and so de- 
structive in consequence of this difference, is no farther accounted for, 
or referred to a sufficient cause, by the assumption. Indeed, it remains 
for future investigation to establish the law of this difference. It has 
been stated that Dr. Hodgkin has proposed an ingenious hypothesis 
to account for these and other morbid growths, — namely, that they 
originate in cysts (not cells or microscopic cysts, but larger vesicles 
comprising these :) and that the multiplication of these cysts within 
each other, — their prolongation into radiated fibres, — their pressure on 
adjoining textures, — and the inflammation, induration, ulceration, atro- 



1 Remarks on the Pathology and Causes of Cancer, Lancet, May 28, 1842. 



MALIGNANT.— NATURE AND ORIGIN. 



413 



phy, or gangrene consequent in these textures, constitute their entire 
history. What appears to me to be chiefly wanting to establish Dr. 
Hodgkin's views is, a more distinct demonstration of the existence of 
the alleged cysts, for, if present, they ought to be distinctly visible at 
the outer limits of cancerous growths during their extension. 

There is one point in the physical history of cancer that is of con- 
siderable interest both in a physiological and in a pathological sense. 
Cancerous growths result from perverted nutrition, but this perversion 
is of a distinctly different kind from degradation, such as is presented 
in tubercle. In tubercle, that which ought to be organized is not or- 
ganized, and is, on this account, incapacitated for becoming a part of 
the living frame. In cancer, the matter is organized and made alive 
too ; but it is organized and vitalized in the wrong way, and is, on that 
account, unfitted for its usual employments. The force that ought to 
be thrown into the development of the individual cells, so that they 
might be altered for structural adaptation, is thrown into their multipli- 
cation and reproduction. Hence the cell germs remain little else but 
cell germs, and are loosely connected together, and multiply with ex- 
treme rapidity, brood after brood, instead of being matured into ela- 
borated tissue-cells, and being then firmly attached together, and fa- 
bricated into texture. The perversion seems to be one of turning 
development into crude multiplying energy, instead of being one of de- 
gradation, that is, of arrest, of retrogradation of development. Hence, 
cancer and scrofula rarely show themselves together, in the same sub- 
ject, although it is, of course, possible that circumstances may change 
the one form of perversion into the other, and that scrofulous persons 
may cease to be scrofulous, and may become cancerous, or the converse. 
Hence, too, the treatment that is appropriate for the one, is, to a cer- 
tain extent, inappropriate for the other. 

As regards the microscopic diagnosis of cancer, it is often very diffi- 
cult and uncertain. The caudate cells and the fibrous stroma are very 
characteristic ; but epithelial cells are frequently so like to the former 
as to be hardly distinguishable from them, especially when they are 
young pavement cells. The microscope detects in cancerous substances, 
molecules and amorphous granules, nuclei, cells of different sizes and 
forms, filamentous fibres, crystalline matters, and exuded blood cor- 
puscles. In fact, it is primarily a granular exudation, which is se- 
condarily converted into cells and fibres, which form an interlacing 
stroma. It will often aid the diagnosis to bear in mind that epithelial 
cells are pretty uniform in size, and exhibit a disposition to run toge- 
ther in groups, and adhere by their edges ; while cancer cells are mostly 
distinct, and separated by interspersed granules and molecules, and 
are very diversified in dimensions. It is only where the distinct cau- 
date cells of varying size, interspersed with granular molecules and 
with fibrous stroma, all co-exist, and there are suspicious general symp- 
toms also, that the case can be considered to be beyond all doubt. 

583. But however uncertain the question of precise origin may be, 
there are some highly important practical facts already gleaned con- 
cerning the nature of cancerous growths. Microscopic examination, 
as well as the general history, pretty clearly shows that they begin in 



414 



STRUCTURAL DISEASES. — GROWTHS. 



limited localities; that they extend by the endogenous and nuclear 
multiplication of their cells which arrests the nutrition of the adjacent 
textures, and diverts the material that ought to be devoted to that, to 
effect the growth of the tumour; that they ultimately infect other parts 
of the body, by sending their nuclear germs to the nearest lymphatic 
glands, and by mixing them with the circulating blood (§ 259,) whose 
streams then convey them to the liver, lungs, and other vascular parts, 
and so induce independent formations there, much in the same way as 
scattered purulent deposits are caused, when the blood is infected with 
pus (§ 470.) Sometimes the cancerous matter is found in clots within 
blood-vessels, and in the coagulable lymph effused by inflammation. 1 

But the history of malignant growths comprises not only the pheno- 
mena of their development in different degrees and forms, but also their 
effects on the adjacent textures; and it seems to me to be possible, by 
a due consideration of both these classes of circumstance, to arrive at 
a better comprehension of many of the modifications which cancerous 
structures present. Scirrhus, the slowest form of the disease, gene- 
rally occurs in persons above the age of forty, in whom the textural 
nutrition is sluggish, and in whom the cancerous matter is very gra- 
dually developed in consequence; the effect on the adjacent textures 
is then to excite inflammation of a chronic kind, and therefore leading 
to induration, often to contraction also (§ 479,) and more or less to ob- 
literation of the natural textures. Hence the hard, knotty, corrugated 
swelling of scirrhus of the mamma, rectum, pylorus, &c, commonly at- 
tended with more or less pain of a peculiar stinging or lancinating 
character, besides various functional disturbances (obstruction to the 
passage of food or feces, severe dyspepsia, vomiting, &c.) The per- 
sistence of irritation in the indurated parts leads (as a matter of course) 
to ulceration (§ 466.) This constitutes what is called open cancer, 
with ragged, inverted, or everted edges, and a fungous or sloughy in- 
terior, that discharges dark, offensive, ichorous matter. That such 
ulcers should be wholly incapable of healing is quite intelligible, when 
it is remembered that the walls are really composed of the cancerous 
structure and of the compressed remains of the natural textures, which 
have become too poor and too much perverted to afford euplastic exu- 
dation. The ulcer often is an outlet for the increasing cancerous mat- 
ter; so that if its discharge be checked by external means, the disease 
is the more likely to spread elsewhere, or to attack other parts : as the 
ulceration destroys the indurated mass, and so removes the barrier that 
has been temporarily erected between the cancerous germs and the 
healthy textures, there is a greater chance of the body becoming more 
generally infected. Hence, too, from the multiplication and diffusion 
of the germs, secondary malignant growths may appear in other parts, 
and are commonly of the softer and more rapidly growing kinds. The 
influence of scirrhous cancer on the general frame is carried to a greater 
degree than that of any other form, perhaps on account of its slow pro- 

1 In a case (which I saw with the late Mr. Avery) of malignant disease of the Inngs 
and deep cervical glands, involving the 8th nerves, there had been recent pleurisy, and 
the bands of false membrane were glistening, and grated under the scalpel from th<s 
presence of cancerous fibres. 



MALIGNANT. — SYMPTOMS AND COURSE. 



415 



gress. Emaciation sometimes reaches a point unequalled in any other 
disease ; and the wasting affects the composition, as well as the bulk of 
organs and textures. Thus bones lose a considerable portion of their 
animal matter, and become so brittle, as sometimes to be fractured by 
the slightest violence. The membranes become extremely thin; the 
omentum often wastes away, excepting a few threads. The lungs ex- 
hibit a remarkable lightness in weight and colour; and I have seen the 
old cicatrices, or consolidations, so frequently found at their summits, 
reduced until almost as pliant as other parts of the pulmonary texture. 1 
But nothing is more remarkable than the ex-sanguine state of the tex- 
tures generally in cancerous subjects. This condition is obvious during 
life in an extreme pallidity, often associated with a sallowness or pecu- 
liar lemon-tint of complexion. 

Scirrhus chiefly occurs after the age of forty; and the more advanced 
the age, the slower generally is the progress of the cancerous disease. 
It has been remarked by Sir Charles Bell, Sir Astley Cooper, Mr. 
Travers, and others, that scirrhus of the breast runs a comparatively 
rapid course at the age of forty-five, but often remains stationary for 
years, and hardly appears to shorten life at the age of sixty or seventy. 
This shows the share which activity of textural nutrition has in causing 
the increase and dissemination of cancerous disease. It is under such 
circumstances that operations for the removal of the morbid growth 
have been most commonly successful; but it must be remembered, also, 
that in such cases they are less strongly called for. 

There is one form of cancer which involves in itself certain very in- 
teresting peculiarities on account of the bearing these have upon the 
histological nature of malignant growth. This form invariably com* 
mences either in the skin, or in mucous membrane, and the diseased 
formation almost entirely consists of flattened cells very nearly re- 
sembling epithelium scales, — hence the variety is termed epithelial. 
It generally commences in some spot that has been exposed to irritation 
for a long time, and progresses very slowly, and it rarely extends to 
any parts beyond the nearest lymphatic glands. It is but little prone 
to assume the malignant type, and does not often return after extirpa- 
tion. The substance, when examined by the microscope, is found to 
consist of layer upon layer of the peculiar compressed cells, some, how- 
ever, either newly formed, or swollen by the imbibition of moisture, and 

1 It appears to me possible that the rare co-existence of tubercle with cancer, noticed 
by some writers, may be due to the former being removed by absorption, during the 
extraordinary wasting of textures which attends chronic cancer. I have twice found, in 
the bodies of persons who died of cancer, considerable remains of tuberculous deposit at 
the apex of the lungs, without any tubercles in other parts. In one case, masses, partly 
caseous, partly calcareous, of the sizes of a pullet's and a pigeon's egg, were thus encysted 
in a thin membrane. In another, there was a cavity in the middle lobe, communicating 
with the bronchi, and traversed by a band of dense tissue, resembling that common in 
tuberculous cavities, and also lined by a thin, smooth membrane. In all these cases, 
the other parts of the lungs were free from tubercles. Now, it does not appear probable 
that such considerable tuberculous deposit should have taken place without there having 
been some in other parts also. Recent tubercle is not met with thus limited to one por- 
tion of the lung. These and similar facts connected with the emaciation of old age, 
seem to me to furnish additional arguments in favour of the possibility of absorption of 
tubercles 561.) For cases of co-existence of Cancer and Tubercle, see Pathol. Trans., 
vol. iii. pp. 254 and 258; vol. iv. pp. 35 and 102. 



416 



STRUCTURAL DISEASES. — GROWTHS. 



round, oval, or even fusiform. When the neighbouring glands are af- 
fected, their substance becomes exactly of the same kind. The cells 
have just the same epithelial aspect. Now, "what is mainly interesting 
in this variety of cancer is, that in different cases every possible shade 
is found between mere simple hypertrophy from multiplication of the 
epidermic or epithelial cells under irritation, to the formation of un- 
questionable cancerous germs. It is often quite impossible, in aged 
subjects, to determine whether small excrescences of the skin are mere 
warts or of a cancerous nature. All this points to modifications of the 
normal operations of the cell vitality — a perversity which causes the 
individual vesicles to multiply their germs, instead of ripening and ma- 
turing themselves — as the most probable cause of the diseased develop- 
ment. When the vesicles are produced more rapidly than they ought 
to be, but are still tolerably perfected in their own intrinsic structure, 
they constitute little more than hypertrophied epidermis, or warts. But 
in proportion as more and more of the immature and over active cell- 
germs are mingled with the matured scales, the growth tends towards 
malignancy of character. It will be observed, then, that this epithelial 
variety of the disease is really scirrfms, occurring in the outer inte- 
guments of the body, where the change can be most readily examined, 
and in its least noxious form. 

584. The pancreatic, mammary, lardaceous, (or pork-like,) and so- 
lanoid, (or potato-like,) varieties of cancer appear to be intermediate 
between scirrhus and encephaloid disease, increasing more rapidly than 
the -former, and yet somewhat resembling it in firmness. They are at- 
tended with comparatively little pain, on account of the smaller degree 
jof tension and induration which they cause in the textures implicated. 
For the same reason they are less disposed to ulcerate (§ 466) or slough 
than other forms (§ 474 :) they commonly prove fatal, either by en- 
croaching on some vital part, or by causing the dissemination of can- 
cerous deposits in other parts of the system. 

585. Encephaloid, (brain-like,) or medullary sarcoma, is the most 
acute or rapid variety of cancerous growth. It occurs chiefly in young 
and middle-aged subjects, and in the most vascular textures ; and its pe- 
culiarity may fairly be connected with activity of molecular nutrition. 
This probably is the cause of the quick multiplication of the cancer- 
germs or cells (viewed as mere modifications of the ordinary cell-germs 
of the textures :) and their elongation and growth into large caudate 
vesicles, and the more or less branching fibres, that form the stroma 
or web of the growth; but much of the speedy increase and early dis- 
semination of this variety of cancerous disease, may also be attributed 
to an active formation of plastic matter, which the presence of the 
cancerous substance excites in the vascular structures. The mass of 
encephaloid tumours comprises false membranes, lymph, and even co- 
agula of blood, in various decrees of organization: mingled with these 
are the peculiar cells and fibres which luxuriate in so fertile a soil. It 
is in connexion with tumours of this kind that the fact already men- 
tioned has been observed, namely, that coagula in veins near the af- 
fected part have exhibited the encephaloid appearance. Coagulable 
lymph, produced by inflammation of serous membranes or of the pa- 



MALIGNANT. — COLLOID CANCER. 417 

renchymata of organs, has done the same thing. The speedily destruc- 
tive influence of this kind of cancer is mainly to be ascribed to the 
rapid dissemination of the cancerous matter, and the bulky deposition 
which it induces around it, which, although organized, and highly vas- 
cular, is beyond the controlling influence of the powers of assimilation 
or absorption, and consequently obstructs or compresses adjacent or- 
gans to a fatal extent. The facility of growth in these tumours receives 
some explanation from the varicose condition ascertained by Mr. 
Kiernan to be present in their vessels, and from their free communi- 
cation with arteries (§ 420,) as pointed out by Schroeder Van der 
Kolk. The same circumstance, taken in connexion with the general 
softness and looseness of their texture, accounts also for the facility 
with which hemorrhage takes place into their substance (§ 357,) causing 
the appearance that has led to the use of the term f ungus hcematodes. 
These forms of disease commonly prove fatal before the emaciating ef- 
fects, so remarkable in scirrhus, have advanced far. 

586. The colloid or gelatinous variety {areolar of Cruveilhier) seems 
to me to present the cancerous element almost in a separate state, and 
but little mixed with natural tissues or their products. According to 
Muller, it consists chiefly of cells contained in a very slight loose web ; 
the cells are larger and rounder than usual, and contain small cells, 
which also enclose cell-germs. The peculiar germinal principle of 
cancer is here, therefore, very abundant and prolific ; but the nutritive 
secretion of the surrounding textures is not equally copious : no distinct 
growths, therefore, are formed ; but the gelatinous matter is infiltrated 
into other textures, and this chiefly in connexion with advanced stages 
of other forms of the disease. 

Additional varieties of cancer have been described, by Dr. Carswell 
and others, as characterized by particular forms in the growth, and 
under the names of the tuberiform, stratiform, ramiform, &c. But 
these are all probably dependent merely on the anatomical character 
of the parts in which they appear, and on the extent and rapidity of 
development. 1 

587. Another morbid production that has generally been classed 
among malignant growths, because it affects many textures and some- 
times supersedes them, is melanosis, black cancer, or black tubercle. It 
most commonly occurs in the form of a loose cellular texture filled with 
peculiar black matter suspended in a serous liquid ; but sometimes its 
substance is quite compact, and in consistence resembles crude yellow 
tubercle, or the lardaceous variety of cancer. I have a drawing made 
from a lung, which exhibits a combination of encephaloid with mela- 
notic substance, the latter of compact texture, like the nodules of pul- 
monary apoplexy, and varying in colour from a dark bistre brown to 
a deep-jet black. A similar combination has also been noticed by 

1 Many interesting particulars respecting the microscopic characters of the varieties of 
cancer will be found in the works of Lebert, Virchow, Hughes, Bennett, Rokitansky, and 
Paget. To the last-named author, in the second volume of his "Lectures on Surgical 
Pathology," I would particularly refer the reader for a masterly exposition of the dis- 
tinctive characters and relations of the several forms of cancerous disease. 



27 



418 



STRUCTURAL DISEASES. — GROWTHS. 



Cruveilhier and Carswell. Andral describes melanosis as occurring 
in four forms: — (1.) It pretty frequently constitutes masses, encysted 
or otherwise; (2.) the matter which composes it may, like the tubercular 
matter, be infiltrated into different tissues ; (3.) it may be spread like a 
layer, of greater or less thickness, on the free surface of membranous 
organs ; (4.) it may exist in the fluid state, either pure or mixed with 
other fluids." 1 

The one characteristic of all these forms is the presence of a pecu- 
liar black matter, which, from the analyses of Dr. Fyfe, M. Tkenard, 
and M. Foy, appears to be a highly carbonized insoluble matter, very 
much like altered colouring principle of the blood. It has been com- 
pared by Andral to the black pigment of the eye, and he considers it 
to be identical with the black deposit commonly found in the lungs and 
bronchial glands. The colouring principle of the blood certainly is 
sometimes changed into a perfectly black matter, as instanced in the 
dark vascular strise and patches that occur in the intestinal canal, par- 
ticularly after chronic inflammation, where the blood has been effused, 
or retained in the vessels, and altered in its physical characters by the 
influence of the secretions and gases. These black appearances are 
called by Dr. Carswell spurious melanosis. The black pulmonary 
matter is clearly a carbonaceous powder stored away in the interstices 
of the textures, and sometimes in the vessels and bronchial glands ; 
but whether it is the colouring matter of the blood in an altered state, 
or an independent deposit of carbon, is not certainly known. All that 
is requisite to convert the colouring principle of the blood into a black 
carbonaceous deposit, is abstraction of a certain amount of hydrogen, 
which the mineral acids are capable of effecting: it seems to be far 
from improbable that a change of this nature takes place naturally 
where black pigment is formed by the agency of peculiar ceils (pig- 
ment cells,) and as a result of disease in melanosis. 

But this production of black matter may co-exist with different mo- 
difications of the nutritive process; it may be associated with plastic 
substance, as instanced in cellular and membranous melanose tumours ; 
with cacoplastic, as seen in hard black tubercle, and in the black con- 
solidations of chronic pneumonia ; or with aplastic, as in the peculiar 
combination of black with opaque caseous matter not unfrequently 
found in the lungs and bronchial glands. So, too, it may be, as pre- 
viously stated, combined with various forms of malignant disease ; but 
I am inclined, with Andral, not to class simple melanosis with malig- 
nant growths. Mr. Paget says that melanotic cancers may have the 
general characters of any of the varieties of medullary cancer, but 
owe their distinctive feature to the presence of numerous pigment gra- 
nules, not unlike the pigment cells of the choroid membrane, and in the 
rete mucosum of coloured skins. They show a remarkable proneness 
to originate in dark moles or pigmentary ngevi which frequently occur 
in the skin, especially in advancing age. 2 

1 " Pathological Anatomy," (Transl.,) vol. i. p. 249. 

2 Lectures on Surgical Pathology, vol. ii., p. 490. 

I take this opportunity of remarking that the formation of black or pigmentary mat- 
ter, both in health and in disease, is a subject which deserves fuller investigation than 



MELANOSIS. — TREATMENT OF MALIGNANT DISEASES. 



419 



588. The treatment of malignant disease has been mostly considered 
to belong rather to the province of surgery than to that of medicine; 
the removal of malignant growths by operation has nevertheless not been 
generally advised by surgeons down to the present time. There is 
much, however, to be deduced from the investigations of physicians 
touching the matter, when and why operations may be expected to be 
successful. The indications of treatment which are suggested by the 
foregoing account of malignant disease maybe summed up under three 
heads: — (1.) To extirpate the malignant growth; (2.) To retard its 
development; and (3.) to counteract its effects. 

The complete extirpation of malignant growths can be effected only 
when they are quite local, so that after their removal by the knife or 
by caustic, no root or stray germs shall be left behind. Reasons have 
been advanced for the supposition that cancer is strictly local at first, 
and if it be completely excised at an early period, permanent cure 
may result. But to ensure this success, it is essential that every can- 
cerous cell be removed; and Dr. Hodgkin has recommended that care- 
ful examination of the tumour should be made immediately after its 
excision, to see that there is no aggregation of cancerous cells on the 
cut surface. These may be detected even by the naked eye, if present. 
Dr. W. Budd advises that the microscope should be employed for the 
same purpose: " If the characteristic cells were found on the cut sur- 
face of the portion removed, it would be morally certain that others 
have been left behind, and that the extirpation is incomplete, although, 
on the other hand, the absence of these cells would be by no means so 
sure a guarantee of their entire removal. Such an examination would, 
however, always be a mater of great interest to the surgeon." 1 The 
best chance of security is afforded by the operation being performed 
before the constitution has been in any degree affected by the disease, 
and before any neighbouring parts, especially lymphatic glands, have 
given tokens of infection. There is therefore most reason to enter- 
tain hope for a successful issue when the growth is chronic, inactive, 
and of small extent, as it is apt to be in scirrhus of the lip, skin, or 
breast. In a general way, the chance of cure from the removal of a 
part affected by cancer is in inverse ratio to the rate at which the 
growth has been developed — for this rate measures the force of the 
malignant diathesis. If any cancerous texture or germs are left be- 
hind, the operation is likely to do harm instead of good, by exciting 

it has received. The readiness with which exposure to the rays of a hot sun, and the 
action of blisters and other irritants cause a deposit of pigment in some skins, is worthy 
of notice. But in some obscure cases this pigmentary deposit in the skin takes place 
abundantly without any assignable cause. Such cases have recently been described by 
Dr. Addison and others, under the title of bronzing of the skin; and the physician just 
named conceives that he has traced a connexion between this affection and diseased con- 
ditions of the supra-renal capsules. I was recently consulted by a lady whose com- 
plexion had changed in two years from comparatively fair to the hue of a mulatto ; the 
parts most exposed to the light being, as usual, the darkest. This patient had resided 
in a malarious district, and her blood was obviously deficient in its due proportion of 
red particles. This and other facts suggest the notion that this black pigment, as in 
the case of the simpler kinds of melanosis, may arise from a degeneration of the red 
corpuscles of the blood, which then become deposited in the situations where they occur 
naturally in the negro. 
1 Lancet, May, 1842. 



420 



STRUCTURAL DISEASES. 



tliem into increased activity, and by so developing the acute form of 
the disease. Instances have occurred in which a cancerous breast has 
been spontaneously removed by sloughing; such events are, however, 
unfortunately very rare. Cauterization is less advisable than excision, 
because it is less manageable. 

589. The second indication — to retard the development of the ma- 
lignant growths — has chiefly been attempted by the employment of 
measures which tend to dimmish the circulation through the diseased 
part. Kepeated local bleedings have been found useful, partly perhaps 
on this account, and partly by relieving the inflammation that is ex- 
cited by the growth. One valuable auxiliary that acts somewhat in 
the same way, and that has long found many advocates, is the appli- 
cation of pressure. Such an amount of pressure as will reduce the cir- 
culation through the part to the lowest degree compatible with its life 
will be tolerably sure to arrest the increase of any morbid growth, by 
depriving it of its nutrition. But for the success of this measure, it 
is no less necessary that the disease shall not have extended to other 
parts besides those to which the pressure is applied, or the growth will 
certainly proceed, in those parts, which are commonly internal ones, 
with a rapidity that is increased in proportion to the outward arrest. 
The best plan for applying pressure is that which has been suggested 
by Dr, Arnott — namely, the application of the slack air-cushion under 
a bandage. It is very doubtful whether medicine possesses any power 
of influencing malignant growths through the constitution. V arious 
remedies have enjoyed an ephemeral repute for their efficacy in cancer. 
Of these, conium has been the greatest favourite. Dr. A. T. Thomson 
was of opinion that the iodide of arsenic has some controlling influence, 
and recently the chloride of bromine has been recommended with the 
same object. But it is doubtful whether any of these agents can do 
more than soothe irritation, and restrain such common inflammation 
with its results, as incidentally attends upon malignant growths. 

590. The third indication to counteract the effects of morbid growths, 
is more commonly the object of treatment; but the means of fulfilling 
it fail more and more as the disease advances. The use of narcotics 
of every description, both general and local, for soothing the pain and 
irritation, and the employment of occasional local antiphlogistic mea- 
sures to obviate inflammation and congestion, are sanctioned by ex- 
perience as valuable palliations in malignant disease. Tonics and a 
nutritive diet may also prove serviceable by arresting cachexy and 
emaciation. They seem to me to possess considerable efficacy in sup- 
porting the constitution, and supplying it with strength to resist the 
enemy that is preying on its vitals. Preparations of iron, when they 
are readily borne by the patient, prove to be the best tonics. The re- 
markable emaciation in cancerous disease appears to point to the cod- 
liver oil, as a nutritive remedy that might be expected to prove advan- 
tageous, but it seems to promote the growth of the diseased structure 
more than to nourish the body. 



DISORDERS OF MECHANISM. 



421 



SECTION X. 
DISORDERS OF MECHANISM. 

591. Many diseases arise from derangements in the mechanism of 
organs, which are not included in the category of any of the conditions 
previously noticed. It would be altogether foreign to the purpose of 
the work, to enter in detail into the consideration of these. But to com- 
plete the general outline, it may suffice to specify the following examples. 

Dilatation. — Hollow organs are liable to be distended, in consequence 
of undue accumulation of matter within them, and this distention may 
become permanent dilatation of their cavities, if it be long continued 
or frequently repeated. The heart, the arteries and veins, the air cells 
of the lungs, the bladder, and portions of the intestinal tube, are the 
organs and structures most prone to be injured from this cause. The 
distention may be caused by obstruction to the forward movement of 
the contents of the several organs, or in consequence of loss of propul- 
sive power in their walls. Mechanical textures are apt to be over- 
stretched and relaxed in consequence of a diminution of elasticity or 
natural cohesion in their molecular composition. Ligaments, tendons, 
and fasciae sometimes become unfitted to perform their offices of bind- 
ing and holding parts together in this way. 

592. Contraction. — -This is precisely opposite to dilatation. Its oc- 
currence, as the result of disease, in the textures of organs and in se- 
rous membranes, has been frequently alluded to in the preceding pages. 
When it takes place in the membranes of tubular parts, it leads to 
stricture, and partial or entire obstruction of the passage through them. 
It is apt to affect the intestines, the urinary and respiratory tubes, and 
the different vessels, in this way. 

593. Laceration. — Living textures may be ruptured or torn either 
by direct violence, or in consequence of disease, and farther structural 
derangements may be induced as a consequence. Rupture of the car- 
diac valves, of portions of blood-vessels and of air cells, is attended by 
this result. But lacerations of the walls of the heart or large arteries, 
of the stomach, of the gall bladder, and of the urinary bladder, are 
speedily followed by death. 

594. Displacements. — Tumours and internal effusions are very apt 
both to compress the textures of organs, and to push them out of their 
proper situation. The heart and lungs are thrust upwards in the chest, 
and the various abdominal organs are forced out of their usual positions 
by ascites, ovarian dropsy, and enlargement of the liver. The paren- 
chyma and air tubes of the lungs are compressed by an enlarged heart, 
and by an aneurismal tumour. Pleural effusion squeezes in the lung 
of the side on which it occurs, and effects displacements of the heart, 
mediastinum, diaphragm, liver, and walls of the chest. 

595. Contortion. — The contortion of rigid parts is exemplified in 
rickets, mollities ossium, and rheumatic nodosities of the joints. Cur- 
vature of the spine changes the position of the ribs, and commonly de- 
ranges the mechanism of respiration in consequence ; and when the de- 
formity is very great, the functions of the heart, great arteries, and 
abdominal viscera, are also injuriously affected to a considerable extent. 



422 



CHAPTER V. 
THE CLASSIFICATION, SYMPTOMS, AND DISTINCTION OF DISEASES. 



SECTION I. 
NOSOLOGY. 

596. Having now considered the causes which produce disease, the 
manner in which those causes operate, the changes that are thereby 
produced both in function and structure, and the different remedial in- 
fluences that can be brought to bear to obviate or correct these changes, 
it remains next to notice the sensible symptoms by which diseased con- 
ditions make their presence manifest, and the way in which these symp- 
toms are varied and combined to constitute special diseases. It has 
been found convenient, in considering the wide range of subjects em- 
braced by general pathology when reduced to the domains of actual 
disease, to group specific disorders into classes and orders, and to sub- 
divide these into genera and species, characterizing the peculiarities 
of each by a definite description. This classification and descriptive 
definition of disease forms what is usually designated by the term No- 
sology. 

597. Diseases have been classed in different ways. The first me- 
thod that was attempted, professed to group them according to their 
most obvious phenomena or prominent symptoms. Of this character 
was the system of Sauvage, who distributed diseases into the ten classes : 
— vitia, febres, phlegmasia, spasmi, anhelaiiones, debilitates, dolor es, 
vesaniw, fluxus, cachexise. The classifications of Linnseus, Yogel, and 
Sagar, were also of the same artificial kind; and C alien's method was 
a strained simplification of a similar plan, which pressed all diseases 
into one or other of the four classes — pyrexiae, neuroses, cachexise, and 
locales. 

The chief objection to this kind of arrangement, which may be called 
symptomatic nosology, is, that it regards symptoms as the essence of 
disease, whereas, in truth, many symptoms are not essential, and even 
those that occur most constantly are extremely variable, both in cha- 
racter and severity, and by no means uniformly express either the na- 
ture or the amount of the real derangement of function and structure. 
Similar symptoms, too, dependent upon the most diverse causes, are 
associated together, although they may require quite opposite plans 
of treatment; whilst diseases that are really kindred in their nature, 
are widely separated, because they differ in their symptoms. The ar- 
tificial method of classification is admissible only as a provisional mea- 
sure, capable of effecting a temporary and conventional arrangement 



CLASSIFICATION OP DISEASES. 



423 



of subjects, pending the investigation of their true nature ; when this 
has been ascertained, or even as the investigation advances, the arti- 
ficial method should give place to a more natural one, which is not a 
mere glossary of names, (or symptoms,) but is able in itself to express 
the most important bearings and facts that have been ascertained. 

598. The appropriate foundation for a natural classification of dis- 
eases is accurate pathology, or knowledge of their intimate nature ; 
but the subdivisions of the arrangement may be conveniently deter- 
mined either by the situation of the derangement, or by some of its 
most prominent characters. The classification of Pinel proceeds upon 
this idea, although it is necessarily imperfect in consequence of the 
infant state of pathology at his period. His nosology comprised five 
classes: — fevers, inflammations, hemorrhages, neuroses, and organic 
affections. 

Pathology may be applied to the classification of disease in two 
modes. It may be made the first step in the arrangement, the several 
disorders being distributed in classes according to the particular pa- 
thological conditions affecting the systems defined by general anatomy. 
Thus, in accordance with the pathological principles that have been 
passed in review in the previous pages, the classes might be — diseases 
of the muscular system, of the nervous system, of the secernent system, 
of the blood, of the vascular system, and of nutrition. The subdivision 
of these classes into orders might then be determined by the constituent 
pathological elements present; thus, diseases of the muscular system 
would group themselves into those of irritability and those of tonicity; 
the generic subdivision of these would be fixed by the excess, the de- 
fect, or the perversion of those properties ; and, lastly, the specific dis- 
tinctions would depend upon the organ or locality affected. This ar- 
rangement, however, is not suitable for clinical or practical purposes, 
because diseases are generally too complex to admit of being easily re- 
solved into their elements : they commonly comprise several elementary 
pathological states, and the relations of these states vary with the pro- 
gress of the case. 

599. The other mode of applying pathology to nosological arrange- 
ment, is to cause it to furnish such distinctions of divisions and sub- 
divisions as may be useful in matters of diagnosis and treatment, whilst 
the remaining divisions are based upon the situation of the disease or 
other circumstances. Thus, as classes we may have, diseases of the 
organs of respiration; of the organs of circulation; of the apparatus 
of alimentation; of that of urinary excretion and of generation; of the 
nervous system; of the organs of locomotion; of the skin; of the blood; 
and lastly, general diseases, having no defined seat. The subdivision 
of these classes into orders may then be founded on pathology: thus, 
each class may be made to comprehend functional diseases, subdivided 
into disorders of irritability, tonicity, sensibility, &c, and secretion; 
inflammatory and congestive diseases ; and diseases of nutrition [struc- 
tural.) A further division into genera and species may be made ac- 
cording to the anatomy of the parts : thus, of the class, diseases of the 
organs of respiration — order, functional disorders; one species would 
be spasm and paralysis of the larynx, another, of the bronchi, &c, 



424 NOSOLOGICAL ARRANGEMENTS. 

But in general diseases, the subdivisions too must be altogether patho- 
logical, or founded on causes or symptoms : thus, fevers are distinguished 
into inflammatory, eruptive, adynamic, contagious, malarious or inter- 
mittent, and continued, as one or the other of these characteristics be- 
comes most available. 

This last kind of classification, although it may be less precise and 
methodical than the others, is the most useful in practice, because it 
most closely follows nature, and, overlooking more minute and difficult 
distinctions, leads the attention at once to the seat and nature of the 
disease, and so renders available those general principles in pathology 
and therapeutics, which form the foundation of rational medicine. 
Another great recommendation in this kind of nosology is, that whilst 
it includes all diseases hitherto distinguished, it also points out others, 
which may and do occur, but which, for want of distinct pathological 
views, have been commonly confounded with such as are more promi- 
nently expressed. 

600. The definitions by which individual diseases are designated 
may refer either to the pathological nature of the disease, or to its 
characteristic symptoms, or to both; and in some instances, the causes 
or results of the disease form essential portions of its history. It 
should always be remembered that the great purpose of nosology is to 
arrange and define diseases in such a manner that the true nature of 
each, and the chief points of affinity and difference by which they are 
associated or contrasted, may be succinctly and obviously expressed; 
and whether these points of affinity or difference are most manifest in 
the causes, nature, and symptoms of the diseases, the arrangement and 
definition should alike mainly take cognizance of them. Thus, in ad- 
dition to its leading peculiar symptoms, the definition of a distinctly 
infectious disease, such as scarlatina, should express its infectious cha- 
racter ; that of a disease indubitably caused by marsh miasmata, such 
as ague, should state this fact; then both being classed as general dis- 
eases, and in the order fevers, the one of the genus eruptive, the other 
of the genus intermittent, a great deal of their intrinsic nature, as well 
as of their distinguishing characters, will have been set forth by the 
mere indication of their nosological position. The farther the know- 
ledge of pathology is advanced, the more considerable part it must 
take in nosological system ; but in the meantime it is expedient to 
render classification and definition as useful as possible, by deriving 
them from all the most available sources, rather than to keep them 
more precise and less applicable until science is sufficiently advanced 
to supply a system that is faultless in every point. 

As this work does not profess to enter upon special pathology, or the 
history of individual diseases, it is unnecessary to proceed into details 
of nosology. The foregoing remarks are intended merely to explain 
the objects of classification, and to introduce the two associated sub- 
jects, semeiology and diagnosis. 



PHYSICAL SIGNS OF DISEASE. 



425 



SECTION II. 

SEMEIOLOGY AND DIAGNOSIS. 

601. Semeiology treats of signs, 1 and, in a medical acceptation, of 
the signs of disease. The word symptom is commonly used by physi- 
cians in the same sense as sign; but, as its etymology implies, 2 it is 
really a more vague expression, signifying coincidence or co-occurrence 
rather than a direct or constant connexion. Some writers (especially 
among the French,) have proposed to restrict the word symptom to 
phenomena manifested by present disease only ; but this is contrary 
to the usual custom, which warrants allusion to precursory and conse- 
cutive symptoms, symptoms of health, &c. Some again have confined 
the term symptom to phenomena that are connected with vital proper- 
ties, and have designated such other phenomena as are more directly 
physical, as signs. This was the sense in which Laennec employed 
these terms, and others have followed his example. Although 'this 
acceptation of the words is not in strict accordance with former usage, 
or with their etymology, it is yet conventionally convenient ; but it is 
as well to render their meaning more precise by prefixing the epithets 
vital and physical, as was first suggested by Bayle, and partially 
adopted by Laennec. 

Let then the word sign, employed in relation to disease, be generally 
understood to imply anything by which the presence of the disordered 
condition is made known. And let symptom express any phenomenon 
which becomes obvious in the course of disease : a symptom may often 
prove to be a sign; but many symptoms are of such uncertain con- 
nexion with a particular disease, that they cannot be said to indicate 
its presence, and therefore they cannot be called signs. The more 
precise designations of physical signs and vital symptoms serve to 
attach a more distinct meaning to the different phenomena of disease ; 
and therefore a brief statement of the grounds of the distinction, and 
of the proper application of the terms, will help to indicate the re- 
spective values of the classes of phenomena to which they appropriately 
belong. 

602. Physical signs are certain material properties of the body, or 
of its constituent organs and textures, which are perceptible to some or 
other of the senses of the observer. Thus, the form, size, colour, firm- 
ness, softness, weight, heat, and odour, of the entire body, may be said 
to afford physical signsfc or evidence of its condition, whether in health 
or in disease. So, also, the form, size, colour, resistance, position, 
temperature, smell, and acoustic properties of any part of the body, 
afford physical signs of its condition, whether in health or in disease. 
Thus it is that the appearance of external deformity or structural al- 
teration, the feeling of a solid tumour, or of the fluctuation of liquid 

1 "Sign, that by wliicli anything is known." — Johnson's Dictionary. 

2 2vfx.7TKxiy.cc, from <rw, with, and nin-vce or 7ttow, to fall. 



426 



SEMEIOLOGrY AND DIAGNOSIS. 



in the abdomen, and the listening to abnormal sounds, produced by or 
in internal parts, furnish physical signs of the presence of disease. 

The discrimination of the difference between the signs of health and 
those of disease, implies an exact knowledge of what is usual in health; 
and this knowledge is derived (1.) from general observation and expe- 
rience of healthy standards, (2.) from anatomical and physiological 
comprehension of what the phenomena of health ought to be ; or (3.) 
from an acquaintance with the particular standard of health in any in- 
dividual case. 

All of these standards are available in instituting a comparison; the 
first is less exact than the other two ; but it is often of considerable 
service nevertheless. Thus, a jaundiced hue of the body, extreme 
pallor or great emaciation, are physical signs of disease which even the 
casual observer cannot mistake. But slighter degrees of the same 
states may be obvious only to those who, through previous acquain- 
tance, know more exactly the standard of health in the individual, and 
can therefore detect the most trifling departure from that standard. 
Again, in local disease : a large tumour or swelling in any part is a 
sign of disease that is manifest to every one; but a smaller or more 
deep-seated tumour may be discovered only by those who have an ac- 
curate knowledge of the healthy anatomy of the part, or by those who 
have previously made themselves familiar with the shape and feel of 
the part in health. 

603. Another means by which the physical signs of disease may be 
distinguished from those of health is through a comparison of parts that 
are naturally symmetrical. Thus, a slight swelling in one limb may 
be readily discovered if it be compared with the corresponding part of 
the opposite limb. A projection or contraction of one side of the chest 
will commonly escape observation until the two sides are compared by 
inspection or by measurement, but the difference will then be at once 
apparent. This method of symmetrical comparison is applicable, not 
only to all external parts and organs, but also to some internal parts, 
which, although not strictly symmetrical in themselves, are yet so far 
equally distributed on the two sides of the body as to give symmetry to 
its exterior. Thus the lungs, in health, are placed so equally on both 
sides of the chest, that they give corresponding motion and acoustic 
properties to each; and percussion and respiration yield similar signs 
on either side. When therefore disease affects one side, it modifies its 
physical signs, and the difference becomes obvious by comparison with 
the signs of the healthy side.- A certain degree of uniformity also at- 
tains in the position of the viscera in the abdomen, so that (making al- 
lowance for the greater bulk of the liver on the right side) any consi- 
derable difference in the shape of resistance of the two sides may be 
interpreted to be a sign of disease. 

604. Where organs are concerned which are not symmetrically 
placed, a previous acquaintance with the natural structure, position, 
and physical properties, is necessary. Thus, the physical signs of dis- 
eases of the heart and liver, cannot be recognised, unless there is 
some healthy standard with which to compare them. This standard is 
soon supplied by careful observation of the signs in health; and an in- 



PHYSICAL SIGNS. — VITAL SYMPTOMS. 



427 



timate familiarity with anatomy and physiology, which teach the healthy 
condition and functions of the body, assists greatly in establishing the 
groundwork for reference. Thus anatomy shows that the heart lies 
naturally behind the lower half of the sternum, and the adjoining parts 
of the cartilages of the left ribs from the third to the sixth; and phy- 
siology points out that its regular double sound should be heard in this 
region : here then is a healthy standard, and when a case is compared 
with this in which the impulse of the heart is felt to beat over a much 
wider space, and the sounds are irregular and masked by grating or 
blowing murmurs, these phenomena are at once felt to be signs of dis- 
ease. Again, anatomy teaches that the liver in a healthy adult ex- 
tends little, if at all, below the margins of the ribs on the right side ; 
and this fact makes it an unmistakeable sign of disease when there is 
dulness on percussion, and resistance to pressure, below these ribs, 
for this proves that the liver is reaching considerably below its usual 
situation. The knowledge of the healthy mechanism and functions of 
the apparatus of respiration, circulation, digestion, and excretion, is 
in many respects necessary to enable us to distinguish the signs of dis- 
ease from those of health : it will guide us to refer signs to their true 
causes ; and indeed often suggests the particular signs which may be 
expected to arise in particular lesions. 

605. Physical signs are phenomena taking place in the body, in ac- 
cordance with certain physical laws. It is therefore obvious, that an 
acquaintance with those laws, as well as with the mere mechanism of 
the body, must assist in the correct interpretation of the phenomena, 
and serve to explain of what they are signs, how they are caused, the 
variations which they may present, and the best mode of appreciating 
them. Thus an aneurism of the arch of the aorta may be detected and 
chiefly studied through the physical signs which it produces. It forms 
a tumour under or near the top of the sternum, pulsating in a distinct 
manner, and with a peculiar sound ; this tumour may press on the air- 
tubes in such a way as to alter their shape, and by partially obstruct- 
ing the passage of the air through them, may also change the sound 
of breathing in the spot: a similar pressure upon the veins may also 
throw their current into unusual sonorous vibration ; or through more 
complete obstruction, it may cause them to swell in a remarkable man- 
ner above the tumour: the aneurism, as it enlarges, also encroaches 
on the lungs, the walls of the chest, the muscles, nerves, bones, liga- 
ments, and other organs, in such a way as to alter their physical pro- 
perties and positions, and thus to give uise to various physical signs. 
Now, all these physical signs are phenomena produced in the altered 
mechanism, in accordance with certain laws; and it is plain, that 
a comprehension of these laws must greatly assist to a ready under- 
standing of the signs, and to a correct tracing of them to their true 
causes. Nay, even the aneurismal tumour itself, alike as regards its 
production, increase, and intrinsic signs, can be rightly understood only 
through the principles of hydraulics and dynamics, considered in con- 
nexion with the structure of the heart and arteries in health and dis- 
ease. 

606. Vital symptoms are those phenomena which depend on the 



428 



SEMEIOLOGY AND DIAGNOSIS. 



vital properties of the textures and of the body as a whole. Thus irri- 
tability, tonicity, sensibility, excitomotion, secretion, and the complex 
functions resulting from combinations of these elementary ones (§ 104,) 
in a natural state, furnish the symptoms of health ; and in a disordered 
state, constitute the symptoms of disease. Hence vital symptoms have 
also been called functional, and physiological ; but both these terms 
are objectionable, because function and physiology have likewise to do 
with physical properties, and therefore concern physical signs. 

Vital symptoms are often less confined in their expression than 
physical signs ; because the vital properties of the entire system are in 
mutual connexion; thus the irritability of the heart spreads its influ- 
ence throughout the vascular system ; the sensibility of one organ or 
part affects the nervous centres, and often through them produces sym- 
pathetic symptoms in other organs or parts (§ 156 ;) disordered secre- 
tion modifies the condition of several parts at once (§ 162 — 7, &c. ;) 
vital symptoms are, therefore, often generally distributed through the 
body. For this reason, they have been sometimes called general symp- 
toms, to distinguish them from physical signs, which are chiefly local; 
but this appellation again is not precise, inasmuch as vital symptoms 
are sometimes entirely local ; as is often instanced in the case of pain, 
spasm, &c. ; and it has been already mentioned, that physical signs are 
sometimes themselves of general import, as illustrated in the yellow- 
ness of the whole surface in jaundice, the swelling of the body in 
dropsy, &c. 

Vital symptoms are sometimes called rational, because their con- 
nexion with some particular cause is rather a matter of inference than 
of direct observation; but this is the most absurd designation of all; 
for observation is necessary as much to teach the value of symptoms 
as of physical signs ; and physical signs are of little use unless they 
are duly made objects for the exercise of reason. 

607. Vital symptoms are exemplified in pain, in uneasiness, and in 
altered and impaired sensations, which arise respectively from exalted, 
perverted, or defective sensibility (§ 125 — 136 ;) in spasm and para- 
lysis, which proceed from excessive or defective contractility (§ 110 — 
118,) or excitomotory power (§ 139—154;) in cough, which is caused 
by irritation or undue excitability of the excitomotory nerves of the 
air-passages and muscles of expiration ; in vomiting, which depends on 
irritation or undue excitability of the stomach and the excitomotory 
nerves sympathetically allied with it ; in dyspnoea, which arises from a 
feeling of want of breath (§ 234 ;) and in fever, which comprises an ac- 
celerated pulse, hot skin, and diminished secretions, &c. (§ 437.) 

Symptoms are further supplied by the state of the different bodily 
functions in which vital properties are concerned. Thus, the state of 
the pulse affords a great variety of symptoms : a frequent or a slow 
pulse indicates increased or deficient excitement or irritability of the 
heart (§ 113, 117 ;) a strong or a weak pulse implies an increased or 
diminished strength of the heart's contractions (§ 112, 116.) A hard 
or sharp pulse is in part dependent on an increased tonicity of the 
arteries (§ 121 ;) whilst a soft, compressible, or liquid pulse, results 
from a diminution of this property (§ 123.) Irregularity in the rhythm 



SOURCES OF SYMPTOMS. 



429 



of the pulse arises from an alteration of the irritability of the heart, 
commonly connected with loss of strength. These various conditions 
of the pulse are sometimes consequences of diseases directly affecting 
the vital properties of the heart and arteries themselves; but more 
commonly they are induced sympathetically by diseases of other parts, 
or through the blood influencing these organs, as instanced in inflam- 
matory fever (§ 437.) Thus, in diseases of the heart and arteries, the 
quality of the pulse has more of the character of a physical sign; 
whilst in other disorders it is rather a vital symptom, connected with 
vital properties. 

The state of the skin is another source of symptoms chiefly depen- 
dent upon the vital properties of the superficial vessels and secernent 
apparatus, and of the general circulation. Thus the heat and dryness 
of the skin in fever arise from accelerated circulation and diminished 
perspiration. When the skin is cold, the circulation is weak ; when 
warm, it is active ; but the occasional occurrence of perspiration in 
both these conditions proves that it is another vital property, namely, 
that of secretion, that is concerned in determining dryness and mois- 
ture of the skin. The signs furnished by the skin are physical, in so 
far as regards the condition of that structure itself ; but they are also 
vital symptoms in relation to the state of the circulation, and to that 
of distant organs, or of the system at large. 

Many important symptoms are furnished by the appearances of the 
tongue. These, w T hen arising from primary disease in the organ itself, 
are really physical signs of its condition. Thus, when the tongue is 
inflamed, it is first red and swollen, and afterwards becomes covered 
with a film or fur, which, separating in patches, leaves the surface red, 
and smoother than before. But in a great many diseases, the tongue 
becomes red, swollen, furred, or brown and dry, in consequence of 
causes that act through the system: and these secondary affections of 
the organ then constitute symptoms of these general diseases. The 
connexion between febrile and other general diseases, and the appear- 
ances which they produce in the tongue, is not well understood ; but 
the appearances probably depend on changes induced in the secretion 
of the mucous membrane and adjoining parts. 

The alvine excretions supply symptoms of great importance in 
various diseases. When they are excessive in quantity, liquidity, and 
frequency, they constitute diarrhoea, which may be primary — that is, 
a disease in itself (§ 374 ;) or secondary, and, therefore, a symptom of 
disease, as in cholera and mucous enteritis. Diarrhoea, as a symptom, 
presents further important indications accordingly as it is feculent, 
bilious, mucous, or watery, for these diversities respectively point out 
that there is accumulation of feces, or excessive secretion of bile, 
mucus, or watery fluid, in the intestines. The opposite condition, that 
of costiveness, is also sometimes a disease itself, and sometimes an 
important symptom of disease, indicating defective peristaltic power, 
or faulty secretion, or both, in the intestinal tube. The quality of the 
alvine evacuation as regards colour, shape, odour, &c, often supplies 
symptoms which lead to a knowledge of the nature of disorder in the 
alimentary canal or in the system. Thus clay-coloured feces indicate 



430 



SEMEIOLOGY AND DIAGNOSIS. 



defective secretion from the liver; those very dark in colour denote 
the presence either of diseased bile or of altered blood; vermicular 
shapes in the dejected mass may result from stricture or contraction 
of the intestinal tube. 

The urinary excretion is a valuable source of symptoms, not only of 
diseases of the urinary apparatus, but also of disorders of other 
organs, and of the whole system. The kidneys being the chief 
emunctories through which foreign, effete, and superfluous soluble 
matters are eliminated from the blood (§ 254,) the urine is continually 
exhibiting changes in quantity and quality, in colour and specific 
gravity, in the character of its sediments, and in the effects which 
different chemical reagents produce upon it. This all furnishes symp- 
toms of several diseases ; but these have been already noticed in detail 
in connexion with the several pathological states involved (§ 167, 176, 
249, 254, 255, 257, 260, 309, 384, 385, 448, &c.) 

608. The foregoing illustrations of the sources whence symptoms are 
derived have been offered merely to point out where and how symp- 
toms are to be sought for ; to complete the list, it would be necessary 
to specify every function of every part of the body, and all the modi- 
fications to which they are subject: this alone would furnish matter to 
fill a large volume. 

As a knowledge of the mechanism of organs, in health and disease, 
and of the physical laws to which that mechanism is subjected, is the 
best aid to the study of physical signs, so an accurate acquaintance 
with the structure and functions of healthy and diseased textures, and 
with the vital laws which influence them, is the best guide to the com- 
prehension of vital symptoms. These symptoms are often obscure and 
unintelligible, because physiology and pathology are imperfect; but in 
proportion as these sciences are improved, their application to the pur- 
poses of semeiology and diagnosis will become more satisfactory. In 
the mean time, much of what is known concerning symptoms rests 
mainly on mere experience ; and until the results of experience can be 
more scientifically arranged it is convenient to consider them numeri- 
cally, in order that some of the general laws which they express may 
be guessed out by empirical means. But to render this statistical or 
numerical method of studying symptoms at all safe, it is necessary 
that the numbers of observations shall be very large, that they shall 
all have been made in similar cases, and that the coincidences which 
are taken as establishing any rule shall greatly preponderate over the 
exceptions. 

609. Physical signs and vital symptoms respectively possess their 
values in making known the nature and extent of disease. Physical 
signs are the more certain, because they appeal most directly from the 
seat of disease to the senses ; they depend on simpler and more con- 
stant causes, physical properties, and are therefore themselves more 
constant, and less subject to variation than vital symptoms, which re- 
sult from more complex, and therefore more variable, vital properties. 
Thus of the indications of inflammation, the redness, heat, and swell- 
ing are physical signs, and these more certainly prove the existence of 
this peculiar mischief than does pain, which is a symptom depending 



RESPECTIVE VALUE OF SIGNS AND SYMPTOMS. 



431 



on the vital property, sensibility, and which is often present where in- 
flammation does not exist (§ 136,) and which may fail to occur when 
inflammation is present (§ 433.) The physical signs of a structural 
disease in the lungs or heart are surer evidence, both of its existence, 
and of its nature, than cough, dyspnoea, pain, or palpitation ; because 
these symptoms may be produced by merely nervous or other causes, 
without the existence of any discoverable alteration of structure. Yet 
vital symptoms, although less sure and constant than physical signs, 
are often more delicate indications, in consequence of being present 
before physical changes become appreciable ; and when they coexist 
with sensible signs, they at once express the nature and amount of dis- 
order in the vital properties of the part, and of the whole system. Thus 
the feelings of chilliness and discomfort which usher in the fever ac- 
companying tonsillitis, are sometimes experienced before the throat 
exhibits the physical signs of inflammation. A slight cough is often 
heard in the early stage of phthisis, before the physical signs of tuber- 
cles can be distinguished. Crepitation in the posterior regions of the 
chest is a physical sign of engorgement of the lung from effusion of 
liquid in the minute tubes ; but we must refer to the accompanying 
vital symptoms to determine whether the engorgement is inflammatory 
or merely congestive. The physical signs of consolidation of the lung, 
and of valvular disease of the heart, are very obvious ; but in order to 
decide whether these affections have arisen from present or recent in- 
flammation, or are the results of old disease, it is necessary to consult 
the vital symptoms ; and this decision is a matter of great importance 
in regard to both prognosis and treatment. 

In short, both classes of indications ought to be carefully taken into 
account by the physician ; and the more fully the physical and vital 
properties which constitute them are understood, the more available 
will signs and symptoms be in leading to correct conclusions, both in 
diagnosis and treatment. 

610. Besides this distribution of symptoms into physical and vital, 
various other plans of classification have been proposed ; but they are 
of little real utility, and it is, therefore, unnecessary to do more than 
succinctly enumerate them. Symptoms are local, or general, and con- 
stitutional, accordingly as they are confined to the diseased part, or 
as they affect the whole system. They are idiopathic, when directly 
proceeding from a primary disease ; they are sympathetic, or secondary, 
when arising from secondary disorders, or such as are produced by 
primary disease. Premonitory or precursory symptoms are such as 
precede the full development of a disorder, and commonly result from 
the first operation of the cause; hence they have been called sympto- 
mata causoe. Commemorative symptoms are such as are developed 
during the previous history of the disease. Anamnestic symptoms, 
such as relate to the previous state of health. Signs have been di- 
vided into objective, those which present themselves to the scrutiny of 
the observer; and the subjective, those described by the patient him- 
self. The objective have been further grouped as active or dynamical, 
those that require some action, motion, or manipulation, for their dis- 
covery ; and passive or statical, those which are obvious without such 



432 



SEMEIOLOGT AND DIAGNOSIS. 



agency. Symptoms are designated by the epithets, diagnostic, 'prog- 
nostic, and therapeutic, accordingly as they are specially applicable to 
the distinction, the foretelling of the event, or the suggestion of the 
treatment, of disease. Symptoms are positive, when they consist of 
phenomena actually present ; negative, when they are expressed through 
absence of phenomena. Of diagnostic symptoms, those are called pa- 
thognomonic or pathognostic, which are peculiar to one disease. A 
single symptom or sign is rarely, if ever, pathognomonic ; but two or 
three taken in combination often are so. 

611. Diagnosis is the distinction of different diseases, one from 
another. It may be based upon their essential nature or pathology, 
or upon those groups of symptoms that are classed as separate diseases 
by nosological arrangements (§ 597.) In other words, the object of 
diagnosis may be either to determine the intimate nature and seat of 
a disease, or to fix its place in some classification by a convenient 
artificial name. In the nosological arrangement, which has been 
alluded to as the best yet contrived (§ 600,) the division of special 
diseases is, so far as is practicable, founded on pathology, or the 
essential nature of the disorder; and therefore diagnosis should also 
have a corresponding reference to this subject. But the admission has 
been freely made that pathology is not yet sufficiently advanced to 
admit of its being the sole basis of nosology: the physician therefore 
frequently has to avail himself of information derived from other 
sources in forming his diagnosis. A considerable portion of his ma- 
terials, indeed, are the results of simple observation or of clinical 
experience ; and these, when they cannot be analyzed by any more 
rational mode, may be advantageously estimated by the numerical 
method, which counts and classes the results of a large number of 
cases. Diagnosis is therefore chiefly based upon semeiology, and the 
results of clinical experience, arranged and interpreted by pathological 
and statistical science. In some instances, the causes and the treat- 
ment of disease aid the diagnosis. Thus the malarious character of a 
patient's residence, and the efficacy of quinine in effecting a cure, may 
contribute important evidence as to the character of a disease. 

612. Diagnosis is general or special. General diagnosis compre- 
hends the distinction between the elements or principles of disease 
(§ 104;) as, for example, between congestion and inflammation; or 
between nervous irritation and structural derangement. Special dia- 
gnosis, on the other hand, relates to the distinction of diseases accord- 
ing to their chief seat, where they have one (§ 599 ;) or otherwise 
according to some other specific difference. Thus, special diagnosis 
discriminates between inflammation of the parenchyma of an organ, 
and that of its investing membrane ; or between an intermittent and a 
continued fever. Special diagnosis also distinguishes the further 
peculiarities of seat or character in disease ; as, for instance, the part 
or extent of a parenchyma or membrane that is inflamed, the type of 
a fever, &c. Special diagnosis is therefore a branch of special patho- 
logy, and should be aided by an accurate and practical nosological 
arrangement. The distinction of two diseases, which resemble each 
other, has been absurdly called differential diagnosis. This is effected 



FOUNDATION OF DIAGNOSIS. — EXAMPLES. 



433 



by marking the signs which are essential to the one, and not to the 
other. The signs called pathognomonic, are therefore the chief guides 
in differential diagnosis. 

613. The best modes for investigating and distinguishing diseases 
vary very much in different cases, according to the nature of the symp- 
toms that are the first to present themselves. This may be illustrated 
by the following problems : — 

General pathology having pointed out the general nature of a disease, 
it is required to determine its precise seat. — Example. In a case in 
which fever, hard pulse, buffed blood, and local pain indicate the 
presence of inflammation, the seat of the inflammation is determined 
by the chief seat of pain or uneasiness (in the chest or side.) by the 
function most disturbed (difficult breathing and cough,) to be in the 
organs of respiration ; by the secretion proceeding from the part 
(rusty, viscid expectoration,) and from the physical signs (impaired 
breath-sound and stroke-sound in part of the chest, with crepitant 
rhonchus,) to be in the parenchyma of the lungs; that is, pneumonia. 
General pathology here commences the diagnosis, but it is completed by 
reference to symptoms explained by physiology and special pathology. 

Previous history, prominent symptoms, or physical signs, having 
pointed out the seat of a disease, it is required to determine its nature. 
Example. — A person suffers from severe pain at the epigastrium ; the 
previous occurrence of symptoms of indigestion and the situation of 
the pain, plainly show the disorder to be seated in the stomach: the 
nature of the disease (whether nervous or inflammatory, &c.) is to be 
determined by general pathology: guided by this, and finding an ab- 
sence of symptoms of inflammation, no increased heat of surface, no 
acceleration of the pulse further than what the pain would cause, and 
no increase of the pain on the imbibition of warm or stimulating liquids ; 
and finding symptoms of predominant nervous properties, and the 
sudden attack, intense • character, and transient duration of the pain 
which distinguish nervous and spasmodic affections, — we decide that 
the disease is gastralgia or gastrodynia, and not gastritis. The dia- 
gnosis which is begun by local symptoms, is completed by reference to 
the principles of pathology. 

Lastly, which is a common case, symptoms being too few or too in- 
conclusive to lead the diagnosis, both the seat and the nature of the 
disease are to be determined. A person complains of general uneasiness, 
weakness, and chilliness, with various functional symptoms, but none 
of a prominent character. Clinical experience has taught the practi- 
tioner that such are the symptoms of incipient fever; and he proceeds 
to investigate farther the nature and cause of the fever. If he finds, 
on close examination of the functions and physical condition of the 
different organs, that one is the seat of marked inflammation, and that 
the fever is not typhoid, he judges that the fever is symptomatic of 
the inflammation ; but if signs of marked local inflammation be absent, 
yet the fever continues with increasing symptoms of depression, weak 
frequent pulse, a brown dry tongue, sordes on the teeth, low delirium, 
&c, he recognises typhoid fever, resulting from the influence of a mor- 
bid poison on the system (§ 105.) 
28 



434 



SEMEIOLOGY AND DIAGNOSIS. 



614. Thus every department of medical knowledge is brought to 
bear on diagnosis ; and in no branch is the information as well as the 
judgment of the practitioner more severely tested than by it. Natural 
shrewdness and tact, with some general knowledge of the nature and 
treatment of disease, may sometimes enable a comparatively ignorant 
person to practise medicine with an appearance of success; but smch a 
person can never succeed with diagnosis ; and he consequently either 
shrewdly evades the subject altogether, or expresses his opinions in 
conveniently vague terms, and scrupulously avoids their being brought 
to the test of the scalpel. The scientific and earnest inquirer, on the 
other hand, feels that this is the subject which demands, above all 
others, the strongest exertion of his mental powers and the keenest ex- 
ercise of his faculties of observation; and that in proportion as his 
senses are well trained for the performance of their work, as his in- 
formation is well arranged in relation to his observations, and as his 
judgment is matured in discriminating and deciding, will be his success 
in detecting the essential and intrinsic nature of disease, and in ap- 
plying his knowledge to matters of prognosis and treatment. 

615. In investigating the symptoms of a case with a view to dia- 
gnosis, prognosis, and treatment, the attention is naturally first drawn 
to such as at once declare themselves in the general aspect of the pa- 
tient, the expression of the countenance, the complexion, the posture, 
the manner of the movements, and the speech ; all these give important 
information to the observing practitioner at a glance, and whilst he is 
interrogating the patient. After the preliminary statements in the 
way of complaint, which are for the most part volunteered by the pa- 
tient, the questions should be directed to the history of the ailment, 
including the previous state of health and habits, with regard to food, 
clothing, occupation, and residence, any former illness, the mode of 
the present attach, and its supposed cause, preceding symptoms, and 
treatment, if any has been employed. The answers to these questions 
will direct the inquiries, in the most efficient manner, towards the pre- 
sent state and symptoms; but the physician should be particularly 
careful never to permit himself to be so far led by the patient's state- 
ments as to omit to examine into the state of all the important. organs 
and their functions. The nervous system and its functions, (sensorial, 
sentient, excitomotory, 'and sympathetic :) the organs of circulation and 
their functions, (pulsation of heart and arteries, capillary circulation 
of surface and visible parts, temperature, state of veins, &c. ;) the or- 
gans of respiration and their functions (breathing, cough, expectora- 
tion, voice, arterialization of the blood;) the organs of digestion and 
their functions (tongue, appetite, and digestion;) the organs of secre- 
tion and excretion and their functions, (liver and intestines, kidneys, 
bladder and skin;) the functions of nutrition and assimilation, (esti- 
mated by the condition of the flesh, and the comparative weight of the 
body;) the organs of locomotion and their functions, (the vigour, firm- 
ness, and power of endurance of the muscles ;) the organs of genera- 
tion and their functions ; these are all subjects for inquiry and physi- 
cal examination to such an extent as may be sufficient to point out 
how far each may be concerned in the production of the morbid results 
under observation. 



OBJECTS OF DIAGNOSIS. 



435 



The object of a "complete investigation of the state of a patient 
should be not merely to determine the particular disease under which 
he may be labouring, but also to discover any peculiarities of health, 
as well as what is morbid, in his condition. The prognosis, or antici- 
pation of the extent and event of the disease, and the judicious selec- 
tion of treatment, require this full investigation. We have to consider, 
not merely disease in the body, but also the body in disease, and it is 
by losing sight of this great practical axiom, that minute or microscopic 
inquirers, who may be singularly successful in special diagnosis, often 
signally fail in prognosis and in practice. 



436 



CHAPTER VI. 



PROGNOSIS— FOREKNOWLEDGE OF THE RESULTS OF DISEASE. 

616. Prognosis is that knowledge which enables the observer to 
foresee the course, duration, and event of a disease. Like the treat- 
ment of disease, it may be either empirical or rational. 

Empirical prognosis is founded on experience or observation only, 
and takes no regard of the nature of the disease or the reasons which 
determine the results. It consists in the recognition of good and had 
symptoms — that is, of symptoms which have in a great majority of 
cases, been followed respectively by a good or a bad result. This 
mode of prognosticating the events of disease was the only one that 
could be pursued in the early ages of medicine. The "prognostics" 
of Hippocrates chiefly depended upon the enumeration of good and 
bad signs ; and the accuracy of the distinctions which he has drawn in 
this sense proves the extent and accuracy of his observation of the 
sources from which his information was derived. The same acute fa- 
culty of empirical prognosis is often acquired to a considerable extent 
by nurses or other non-medical attendants of the sick. These can 
often tell when a patient is getting better or worse, by the appearance 
of the countenance, by the state of the voice, by the condition of the 
mental faculties, of the strength, of the breathing, and of the excretions, 
although they may be in complete ignorance of the nature of the dis- 
ease, and why the signs are good or bad. This kind of prognostic 
knowledge, although useful in enabling a person to pronounce what the 
existing state of a patient may be, falls far short of that which ought 
to be possessed by the scientific practitioner, who should not only have 
a greater number of prognostic symptoms within his reach, but should 
be able to foresee them, so as to anticipate, and, if possible, to influ- 
ence them in a favourable manner. 

617. Rational prognosis comprises the estimation of the importance 
and tendencies of a disease from a knowledge of its causes, of its in- 
trinsic nature and symptoms, and of the power of treatment in regard 
to it. Like rational diagnosis (§ 614,) it takes its evidence from all 
available sources, and makes the best possible use of this evidence by 
analyzing it, and so determining its precise value. Thus, in the early 
stage of inflammation of the lung, the discovery of the nature and seat 
of the affection at once indicates the presence of a serious disease, what- 
ever may be the state of the present symptoms. The practitioner, in 
forming a rational prognosis, takes into account the extent of the in- 
flammation, knowing, from experience as well as from reason, that this 
is a source of danger : he also ascertains the duration of the attack, 
and from the existing signs and symptoms judges whether the mischief 



EMPIRICAL AND RATIONAL. 



437 



is increasing or not. These considerations give him some insight into 
the severity of the disease, but his prognosis is then determined by 
further reflections. He knows that inflammation of the lungs, although 
always a dangerous disease, becomes much less so when it is at a stage 
and in a subject in which antiphlogistic remedies can be well borne: 
thus, at an early period, in a young and vigorous subject, even the 
most extensive inflammations may be cured by blood-letting and other 
means judiciously employed; but if the disease has advanced far, and 
the function of respiration has been for some days impaired by it; and 
if the subject be feeble, from infancy, from extreme age, from previous 
disease, from intemperate habits, from a complicating disorder, or from 
any other cause, the prognosis becomes more unfavourable, inasmuch 
as there is then little power in the system to bear the lowering in- 
fluence of the appropriate remedies, or to withstand the effects of the 
disease itself. 

To take another example. In continued fever, certain symptoms 
have been found by experience to be of an unfavourable character. 
The pathological practitioner profits by this experience, but he ana- 
lyzes the results and goes farther. Knowing that the occurrence of 
petechias, congested face, and stupor, at the commencement of fever, 
are bad symptoms, he is also aware that they are so, mainly in propor- 
tion as they arise from the changed state of the blood induced by the 
depressing cause of the fever ; and that when, as sometimes happens, 
they appear without a corresponding depression of the heart's power, 
manifested by extreme frequency and weakness of the pulse, they are 
by no means of such unfavourable import, but may arise from mere 
plethora of the subject. Again; symptoms referable to the excitomo- 
tory system (§ 153,) — such as subsultus, hiccup, and convulsive affec- 
tions, — are generally unfavourable in continued fever ; but they are so 
only when caused by the severe operation of the febrile poison on the 
nervous centres ; they are of much less consequence when occurring in 
a nervous subject, in whom slight causes may induce them. The same 
remark may be made in regard to stupor, which is of most serious im- 
port when dependent on fever alone; but which may be induced by 
very slight agencies in hysterical subjects. The scientific pathologist 
is acquainted with these differences, and forms his prognosis accord- 
ingly. He can trace the danger of bad symptoms, beyond the symp- 
toms themselves, to those interferences with vital functions which ren- 
der those symptoms dangerous, and of which the symptoms are not 
always the true exponents. 

618. As the limits of the work preclude the introduction of details, 
it must suffice here to enumerate the chief circumstances from which a 
rational prognosis is formed, and to illustrate them by examples. These 
may be arranged under the two general heads ; 1. those relating to the 
patient or subject; and 2. those referring to the disease. 

619. The age of the subject. — Acute diseases are ill borne at either 
extreme of age, for the powers of reaction are then less energetic 
and less able to sustain the struggle. Hence infants and aged persons 
are often carried off by acute attacks. Acute diseases prevail more in 
the young and in middle age, than in advanced life, in which affections 



438 PROGNOSIS — FOREKNOWLEDGE OF RESULTS OF DISEASE. 



tend to assume a chronic form; also from want of that power of reac- 
tion and resistance by which in more vigorous age morbid actions are 
thrown off. 

The sex of the patient. — Nervous diseases are most common and ob- 
stinate in the female sex ; but they are more serious as regards their 
results in the male sex. The occurrence of the catamenia is often fa- 
vourable, as their suppression is unfavourable, in the course of a dis- 
ease. Pregnancy and lactation suspend or retard the progress of tu- 
berculous, and other disorders of the nutrient function, but the cessa- 
tion of these conditions often excites the suspended mischief into fresh 
activity. Eruptive fevers, especially small-pox and scarlatina, are pe- 
culiarly fatal to women during and shortly after pregnancy. 

The temperament of the patient. — In the sanguine temperament dis- 
orders are apt to be acute, and to tend to a speedy termination, favour- 
able or unfavourable; in the phlegmatic temperament, they are more 
inclined to be chronic, and the symptoms are latent or obscure ; in the 
nervous temperament the symptoms become very prominent, and often 
cause much suffering and alarm when little or no real danger exists, 
and are likewise remarkable for their mutability. 

Previous diseases of the patient — The same disease having occurred 
before, either prevents or renders milder a subsequent attack, in the 
case of eruptive fevers, hooping-cough, &c. ; but this increases the ten- 
dency to recurrence, and the danger, in case of apoplexy and most 
structural diseases. Albuminuria with dropsy is more curable, when 
ensuing after scarlatina, than when induced by other causes; but rheu- 
matism following scarlatina and gonorrhoea, is often unusually severe 
and intractable. After continued fevers and other debilitating dis- 
eases, inflammations often assume a subacute or chronic form, in which 
they are liable to escape attention, and to produce serious organic dis- 
ease. 

Present diseases of the patient. — These generally increase the se- 
verity or intractability of any additional disorder, especially if they 
be structural. Thus infectious disorders and fevers are peculiarly fatal 
in persons who have diseased heart, lungs, kidneys, or brain. But mo- 
derate hypertrophy of the heart is rather a favourable circumstance in 
phthisis. Cutaneous, and some other external diseases, occasionally 
suspend attacks of gout, gravel, diarrhoea, &c. Extensive emphysema 
of the lung supersedes tubercles, and most other lesions of the paren- 
chyma, but makes the bronchial surface and liver the seat of almost 
constant congestion or inflammation. Cancer arrests tuberculous dis- 
ease, and reduces the proneness of the subject to inflammation. 

Previous habits of the 'patient. — Habitual intemperance and excesses 
of all kinds enhance the danger of all serious attacks and accidents. 
Extreme privations and exhausting employments make persons liable 
to fevers and other depressing diseases, and reduce the powers that 
react against them ; and so also do close confinement and want of sleep. 

Condition of the patient at the time of the attack. — Extreme weak- 
ness, or exhaustion from whatever cause, renders persons bad subjects 
for most diseases. Plethora increases the intensity of inflammatory 
affections. Simultaneous excitement of any organ, as for instance, of 



PROGNOSTIC SYMPTOMS — MODE OP DEATH. 



439 



the brain by moral influences, is very apt to add a dangerous compli- 
cation to continued fever. 

620. The cause of the disease. — Epidemic, endemic, and infectious 
disorders, are mostly serious in proportion to the intensity of their 
cause. Thus the endemic of a hot climate is more dangerous than that 
of a cold climate: an infectious disorder propagated in close habitations 
is more severe, on account of the concentration of its exciting poison 
and of other co-operating influences, than one that arises from more 
diluted and simple infection. Some estimate may generally be formed 
of the probable severity of a disease, if the character of its source is 
known. 

The situation and nature of the disease. — The more important to 
life the part attacked is, and the more the disease interferes with the 
function of that part, the greater is the danger. Thus the heart, the 
lungs, the medulla of the nervous system, the kidneys, and the blood, 
cannot be extensively attacked by disease without great risk to life ; 
and if the disease goes on to affect structure, as in inflammation, the 
danger is enhanced in proportion. In a few cases disease attacking 
an unimportant part, as the skin or an extremity, may prove dangerous 
on account of its tendency to spread to other parts or to infect the 
whole frame, as in the instance of cancer, gangrene, inoculated poisons, 
and hydrophobia. 

The extent and progress of the disease. — The greater the extent of 
the disease, generally, the more serious it will be, if the case be one of 
inflammation; but sometimes the severity of the symptoms is not in 
proportion to the extent of the mischief: intense and circumscribed in- 
flammation causes more marked symptoms than that which is extensive 
and diffused. The rate of the progress of disease materially influences 
its effect on life and health. Thus the structure of the lungs, heart, 
kidneys, or liver, may become diseased to a very extraordinary extent, 
without destroying life, if the advance of the lesion is gradual ; whilst 
a third or fourth of the same amount of mischief would prove fatal, if 
induced suddenly. 

621. The character of the symptoms. — Those symptoms augur fa- 
vourably which show a power of moderate and regular reaction, and a 
return of the functions to their natural state. The removal or allevia- 
tion of the more distressing symptoms of disease — the restoration of 
the natural appetites, and feelings, bodily and mental — the regaining 
of strength — returning regularity and moderation of the pulse and other 
signs of equalized circulation — the disposition to sleep tranquilly, and 
wake at the usual times — the renewal of interrupted or diminished se- 
cretions, often in increased quantity, as if after accumulation, as in the 

case of critical perspirations, deposits in the urine, &c, (§ 448,) — are 
the chief signs of approaching recovery. 

622. Bad or unfavourable symptoms are such as arise from impedi- 
ment to one or more of the functions immediately concerned in the 
support of life, namely, the circulation of the blood, respiration, nutri- 
tion, or excretion. In proportion as these functions are speedily or 
extensively impaired, life is threatened, and there is an approach to- 
wards its arrest, by one or other of those terminations, which are called 



440 PROGNOSIS — FOREKNOWLEDGE OF RESULTS OF DISEASE. 



modes of death Thus there is death by syncope — cessation of the 
circulation; by asphyxia, or apnoea — interruption of the respiration; 
and by inanition. To these may be added, death from the pernicious 
influence of excrementitious matters, and other poisons, which operate 
in various ways. These different modes of death are most distinctly 
exhibited when they are brought about so speedily as to leave the func- 
tions, which they do not directly affect, comparatively vigorous and as 
it were outliving that which has been more seriously injured. Thus, 
in sudden death from arrest of the respiration, the heart continues to 
act for some time, until the death which has begun with the breathing 
function reaches its intrinsic vitality also. 

623. If we farther trace the operation of these different modes of 
death, we shall find that they all agree in affecting the blood, either 
by altering its composition, or by arresting the circulation ; and that 
it is through one of these means that death extends to all the functions 
of the frame. Thus in death from cessation of the heart's action, the 
circulation is at once arrested, and every part deprived of the material 
support of its vitality ; hence this is the most speedy death that can 
happen. Inanition obviously operates by reducing the circulating ma- 
terial, and by ultimately weakening the organs by which the circulation 
is carried on. Asphyxia, we have already found (§ 235) both to im- 
pede the circulation and to alter the condition of the blood. Excre- 
mentitious matter retained in the blood, and extraneous poisons, ad- 
mitted into it, operate in various ways: sometimes by impairing the 
irritability of the heart; sometimes by injuring the medullary nervous 
function (§ 154,) on which respiration depends; sometimes by arresting 
the passage of blood through the capillaries, (§ 298;) and sometimes 
(and this probably includes one or other of the former modes) by so 
changing the properties of the blood itself, as to render it unfit for its 
office of sustaining the activity of the several vital functions: the fatal 
operation of all poisons may thus be traced, like other causes of death, 
to derangement induced in the circulation or in the composition of the 
blood. It is the more necessary to keep these points in mind, because 
they explain why death from disease often takes place without begin- 
ning obviously in some one set of functions; all then fail together from 
want of proper blood, their natural support. 

624. It may be as well to specify more particularly the principal va- 
rieties of the several modes of death, and to mention such symptoms, 
as may become available in prognosticating the approach of death. 

Health (cessation of function) beginning at the heart j |^ jJual — asthenia 

— — beginning at the breathing apparatus = Asphyxia or apnoea. 

— — beginning at the brain = Coma. 

— — beginning at the nervous medulla = Paralysis. 

— — beginning in the blood = Necreemia (renooc, dead; aiua, blood.) 

625. Death by cardiac syncope, or sudden cessation of the heart's 
action, may occur in two ways — 1. By this muscle losing its irritability 
(§ 116,) so that it ceases to contract; and, 2. By its being affected with 
tonic spasm (§ 114.) so that it remains rigidly contracted, and fails to 
enter upon its usual alternation of relaxation. In both these cases, 



MODES OF DEATH. 



441 



death is quite instantaneous: the subject suddenly turns pale, and falls 
back or drops down, expiring with one gasp. In the first instance, 
both sides of the heart are, after death, found to be distended -with 
blood; and if the examination be made soon after death, the blood in 
the left cavities is observed to be florid. In the second instance, the 
heart is small and very hard; the ventricles (especially the left) are so 
firmly contracted, that their cavities are almost obliterated, and con- 
tain no blood; the muscular substance is very firm; but in two or three 
days (particularly after maceration in water,) the walls of the ventri- 
cles yield to the pressure of the fingers, and the cavities may be re- 
stored to their normal dimensions. This state of the heart was long 
mistaken for concentric hypertrophy, until Cruveilhier and Dr. G. 
Budd pointed out its true nature. 

Although syncope by loss of irritability (paralysis) and syncope by 
spasm appear to be opposite states, yet they arise from somewhat simi- 
lar causes. Wounds of the heart are followed sometimes by the one, 
sometimes by the other. Death by shock, instanced in the tearing off 
of a limb, the infliction of a violent blow on the epigastrium, and the 
crushing of the brain or spinal marrow, is sometimes caused by spasm, 
but more frequently by paralysis, of the heart. In sudden death in- 
duced by drinking a quantity of raw spirits, or of very cold water when 
the body is heated, the heart has been found contracted. 

Syncope by loss of irritability of the heart is the more common oc- 
currence ; it may be caused by the operation of large doses of certain 
poisons of the sedative class — such as the upas antiar, infusion of to- 
bacco, aconite, and digitalis; and in combination with other effects, by 
that of hydrocyanic acid, strychnia, 1 oxalic acid, arsenic, preparations 
of baryta, and various animal poisons. Mr. Blake proved experimen- 
tally that the power of the heart is destroyed by the injection of solu- 
tions of various saline matters into the veins, especially of salts of potass, 
magnesia, zinc, copper, lime, baryta, and lead; but these results do 
not correspond with what is ascertained to be the influence of the same 
substances when introduced into the stomach. 

The diseases in which death by cardiac syncope sometimes takes 
place are — structural lesions of the heart (but more rarely than is com- 
monly supposed;) hemorrhagic apoplexy, attended with much injury 
to the substance of the brain (§ 364 ;) ansemia (§ 270 ;) and adynamic 
fevers (§ 105.) As this result occurs instantaneously, there can 
scarcely be said to be symptoms ; but sometimes an approach to it is 
manifested in attacks of common syncope or faintness, in which the ac- 
tion of the heart becomes weak, irregular, and intermittent ; and the 
partial failure of the circulation is evinced in the paleness of the face, 
lips, and general surface, together w r ith cold perspiration ; and there is 
suspension of the sensorial functions (defectio animi,) — loss of con- 
sciousness and volition, more or less complete, sometimes attended 
with various convulsive movements (§ 153, 265) — the eyes turning up 
or becoming fixed or glazed, and the pupils dilated. The effects of 

1 In my own experiments the heart was always found distended in animals poisoned 
by strychnia. In the late trial of Palmer some of the medical witnesses stated that it is 
sometimes found contracted. 



442 PROGNOSIS — FOREKNOWLEDGE OF RESULTS OF DISEASE. 

altered posture on syncope have been already alluded to (§ 70 ;) and 
they may be observed in cases which ultimately prove fatal. The re- 
covery from this faintness is often attended with shivering, vomiting, 
sighing, gasping, yawning, and various distressing sensations of noises 
in the head, flashes in the eyes, palpitation, depression of spirits, &c. ; 
the pulse, in the meantime, regaining its strength and regularity, and 
the colour and warmth returning to the surface. Subsequent reaction, 
like that which occurs after great losses of blood (§ 266, 362,) is very, 
apt to ensue. 

626. Death by the gradual cessation of the heart's action has been 
termed asthenia, (a, not, aSsvM strength.) This is the way in which 
many diseases terminate, especially those which destroy life by exhaust- 
ing the strength, without exerting any direct interference with the 
more vital functions. Long-continued fevers, delirium tremens, gas- 
tritis, enteritis, peritonitis, and occasionally tetanus, hydrophobia, and 
inflammation of the brain ; hemorrhages, and various discharges of ani- 
mal fluids — such as diarrhoea, diabetes, and the suppuration of exten- 
sive ulcers or abscesses, want of sufficient food, and several other like 
influences, thus reduce the power of the heart, and with it the vigour 
of the functions of the whole body, to a lower and lower state, until at 
length the heart flutters, and dies. 

The symptoms of the approach of death by asthenia are — augment- 
ing weakness of body and mind, probably without marked derange- 
ment of any particular function of either; increasing frequency, and 
diminishing strength of the pulse; the face, lips, and skin generally 
become gradually paler and paler, or of a death-like sallowness ; the 
extremities lose their warmth, and often become cedematous; the ap- 
petite fails; the tongue is sometimes dry and brown, sometimes furred, 
and the mouth aphthous (§ 483;), the excretions at first are imperfectly 
voided; then the sphincters lose their power (the weakness reaching 
the seat of the excitomotory function,) and involuntary discharges of 
urine and feces take place. This state si sinking terminates in death in 
a few hours. The symptoms thus described depend upon progressive loss 
of power, not confined to the heart, but through its failure, and that of 
the circulation of the blood, of which it is the chief instrument, becoming 
extended throughout the whole frame. But with this general debility 
there are often indications of partial excitement and attempts at reac- 
tion, which sometimes mark the sinking state. Thus a febrile excitement 
of a hectic kind (§ 471) is very apt to come on, giving slight temporary 
strength to the pulse, a flush to the cheek, life to the eye, and a sort 
of flickering reanimation to the whole frame. Sometimes the excite- 
ment is more partial, affecting the brain, with a sort of delirium ; or 
the medulla, and inducing subsutius tendinwm, hiccup, and other slight 
convulsions; or the stomach, and causing vomiting, &c. Often, in the 
sinking state, some functions become obscured before others, in conse- 
quence of congestions, effusions, or even low inflammations occurring 
in the capillary vessels of their organs (§ 290.) as the powers of the 
general circulation fail: thus, death by asthenia may become somewhat 
complicated with the coma of congestion or effusion within the head; 
or with dyspnoea from congestion in the lungs : or somewhat similar 



MODES OF DEATH — APNCEA. 



443 



symptoms may arise from the early failure of the excreting organs, 
and the consequent retention of excrementitious matter in the blood 
(§ 249.) 

627. Asphyxia or apnoea has already been noticed as an element of 
disease (§ -34,) and its nature and symptoms have been so far examined 
(§ 235;) it must here be adverted to as a mode of death. By death 
^beginning at the breathing apparatus, is intended to be expressed that 
in •which the function of this apparatus is the first to fail. In this re- 
spect it is distinguished from death beginning at the brain or spinal 
medulla, which destroys by secondarily suspending the function of 
breathing, and the distinction is useful for practical purposes, since it 
serves to direct attention to the most suffering organ. Death by sim- 
ple apnoea takes place in diseases of the lungs and air-tubes, in vrhich 
the entrance of air to the lungs is impeded by effusion into these cavi- 
ties ; or by pressure upon them, as instanced in bronchitis, pneumonia, 
and pleurisy; or by obstruction to the passage of the air through the 
trachea or larynx, as occurs in croup, laryngitis, and tumours or spasm 
constricting the bronchi and cells ; or by circumstances which mechani- 
cally prevent the entrance of air by the mouth and nostrils, as in 
smothering, strangling, hanging, and drowning. 

The symptoms of the approach of this mode of death are — an in- 
creasing feeling of suffocation or want of breath, which becomes most 

OS 7 

distressing and agonizing if the want be unappeased ; the efforts at re- 
spiration are made in a hurried and forced manner; the face, neck, and 
other parts of the surface become congested in proportion to the vio- 
lence of these efforts ; and as they are unsuccessful, the colour of the 
congested parts changes from red to purple, and from purple to livid. 
The influence of the congestion and partial circulation of black blood 
(§ 235) soon tells upon the several vital functions, and becomes mani- 
fest in stupor, reduction of temperature, weak and irregular pulsation, 
rapid reduction of muscular strength, and consequently of the efforts 
to breathe. Hence the dark hue of the face is ultimately changed to 
paleness ; but the lividity of the lips, tongue, nails and other coloured 
parts remains. In cases of speedy death from violence, as in hanging 
or drowning, or from a sudden attack of laryngitis or spasm, the re- 
spiratory efforts are more vigorous, and the congestion and lividity of 
the surface are greater and more persistent. But in the slower as- 
phyxia of disease of the lungs and air-tubes, the interruption to the breath- 
ing is less complete, the efforts are less violent, the congestion of the 
surface is less marked, and the functions fail more gradually and 
equally, and so the symptoms peculiar to apnoea are less decided, 
Here, too, as imperfectly arterialized blood is circulated throughout 
the body, this often causes peculiar symptoms, such as stupor and low 
delirium, partial paralysis, vomiting, relaxation of the sphincters, and 
other indications of sinking. This exemplifies what has been before 
remarked (§ 622,) that the distinctness of the mode of death generally 
depends on the speedy supervention of the result. 

As matters of prognosis, the symptoms of apnoea are more hopeless 
in proportion as they are conjoined with those of debility. The nature 



444 



PROGNOSIS — MODES OF DEATH. 



of the obstruction to the respiration must also of necessity be taken 
into account ; if this be not complete, nor its cause irremovable, the 
congestion and lividity of the surface are not fatal signs, so long as 
the strength of the breathing apparatus and of the heart does not de- 
cline; but as this becomes exhausted, the means of recovery are lost. 

628. Death by coma, or beginning at the brain, is caused by various 
influences which primarily destroy the functions of the superior masses 
of the nervous system. The chief of these circumstances are — obstruc- * 
tions to the circulation through the brain by pressure, (of effused blood, 
pus, lymph, or serum, of distended vessels in apoplexy, of a depressed 
portion of bone in fractured skull, and from coagula, within the vessels 
in anoemia) (§ 267:) and the influence of various narcotic poisons, such 
as opium, alcohol in large quantities, carbonic acid, ether, or chloro- 
form, introduced by inhalation (§ 128, 246,) and sometimes the excre- 
mentitious matter of urine and of bile in the blood (§ 249.) 

The symptoms of coma, dependent upon the interrupted function of 
the brain, are insensibility and suspension of voluntary motion, the 
heart's action not being materially disturbed. These may come on in 
different modes. In apoplexy and after injuries of the head they ge- 
nerally supervene suddenly, and the patient at once becomes powerless 
and senseless, the pulse continuing pretty good, although slower and 
fuller than usual, or it may be frequent from mere sympathy. In 
other cases, the stupor advances gradually, the senses and mental 
powers are irregularly obscured, and there are dimness of sight, ap- 
pearances of clouds or cobwebs before the eyes, muscce volitantes ; va- 
rious imperfections of hearing, odd noises, or tinnitus aurium; numb- 
ness and tingling sensations in the limbs ; loss of memory, confusion 
of ideas, hallucinations, low delirium alternated with stupor (iyplioma- 
nia;) continued somnolency, &c. Partial paralysis often accompanies 
progressively advancing coma, sometimes it seizes on the lower extre- 
mities (paraplegia,) more commonly upon one side of the body (hemi- 
plegia.) In the operation of narcotics, the state of coma is commonly 
preceded by cerebral excitement, manifest in the usual signs of intoxi- 
cation and delirium, but varied in the case of different poisons. For 
these particulars, however, works on toxicology and materia medica 
are to be consulted. 

In conjunction with these symptoms, referable to disturbance of the 
sensorial and voluntary functions, there are often various affections of 
the excitomotory system of the spinal medulla ; at first these are of the 
nature of excitement, such as convulsion, vomiting, hiccup, contracted 
pupil, &c. (§ 152.) Thus, the coma of apoplexy, and the stupor of 
narcotism, are occasionally accompanied by convulsions (§ 150,) gene- 
ral or local. I have elsewhere (§ 153) endeavoured to explain how 
these opposite effects may arise from the influence of the same cause 
on different parts of the nervous centres. But in cases of extreme 
coma, the excitomotory power that leads to involuntary motions, be- 
comes impaired, the breathing is stertorous and imperfect, the actions 
of coughing and expectoration are not easily effected, deglutition be- 
comes impossible, the pupils are dilated, emetics fail to excite vomit- 
ing, the sphincters are relaxed, and involuntary discharges of urine and 



DEATH BY COMA. 



445 



feces take place. The last group of symptoms have been already no- 
ticed as of fatal import in coma and narcotism (§ 154.) 

It is a question whether the functions of the brain can be completely 
suspended for any length of time without those of the spinal medulla 
suffering also. During common sleep there is not complete insensibi- 
lity or suspension of volition, for movements are made in it under the 
influence of unpleasant sensations, without the sleep being broken. It 
is probable that in the trance of nervous subjects — of hysterical coma 
* — (§ 141,) neither sensation nor volition is entirely abolished; but it 
is difficult to ascertain the truth in these cases, for the patients often 
deceive themselves as well as others. But in the heavy sleep of intoxi- 
cation, and in the stupor of coma, where pinching scarcely excites any 
evidence of consciousness, the functions of the spinal medulla seem to 
be impaired, as well as those of the sensorium, for the breathing is slow 
and stertorous, and irritations of the nose and eyes less readily than 
usual excite the motions of sneezing and winking. It is in proportion 
as these functions are impaired that coma becomes dangerous ; and it 
is because they are not impaired (but in some instances distinctly ex- 
alted, as manifested by the sighing and spasmodic twitching that occur) 
in nervous or hysterical stupor, that this is unattended with danger. 
It appears probable, however, that coma, when complete, may cause 
death by the abolition of sensation only, and if so, we are warranted 
in distinguishing between death by coma and death by paralysis of the 
spinal medulla. Although the movements of breathing are ordinarily 
independent of the consciousness or will, yet such is not the case with 
regard to the extraordinary movements which are performed in breath- 
ing deeply or sighing, when the usual action is impeded by a confined 
position, fatigue, exhaustion, or some special debilitating cause. Under 
these circumstances, when the function of the brain is unimpaired, the 
feeling of want of breath arouses a succession of voluntary efforts, 
which issue in suspirious breathing, and which are the cause of the 
sleeplessness of delirium tremens, and other states of exhaustion 
(§ 154.) But when sensibility and voluntary power are wholly sus- 
pended, these supplementary efforts are not made; for want of them, 
the respiration is then insufficiently performed, and the lungs and air- 
tubes gradually become congested; this congestion and the secretion 
consequent upon it further impair the involuntary part of the process, 
and thus without any indications of paralysis of the spinal medulla, the 
symptoms and effects of apnoea are slowly superinduced on the state of 
coma. Under such circumstances, it is of great importance to place 
the patient in postures and circumstances that are most favourable to 
the movements of breathing, and to attempt to remove pulmonary con- 
gestion by appropriate remedies, should it arise. 

Snoring arises from a relaxed state of the soft palate, and is of little 
moment so long as the movements of breathing are duly strong and 
frequent ; but when the respiratory powers are weakened, stertor is 
not only a sign, but a cause also of obstruction to the passage of the 
air, and should be prevented as much as possible by changing the pos- 
ture of the patient. 

The most dangerous kinds of coma, then, are such as are attended 



446 



PROGNOSIS — MODES OF DEATH. 



by symptoms of impaired excitomotory function, or such as are so 
profound and prolonged, as to deprive the respiration of all aid from 
voluntary efforts; the signs of danger are therefore particularly con- 
nected with the state of breathing. In apoplexy, contraction of the 
pupil of one or both eyes is of very unfavourable import, because it 
indicates that there is irritation of the upper portion of the spinal 
medulla, as "well as oppression of the brain: such a combination can 
only proceed from the influence of a blood-clot upon the substance of 
the nervous centres, compressing one part and irritating another. 

629. It is quite intelligible why death ensues from injured f unction 
of the medulla oblongata and spinalis, when it is considered that the 
ordinary act of breathing depends upon this portion of the nervous 
centres. This mode of death, like the last, is of the nature of apnoea ; 
but the failure here begins with the nervous link of the chain of actions 
which constitute the process of respiration ; whereas in simple apnoea, 
it commences in the mechanism of the breathing apparatus. 

This form may be called death by paralysis, and as in other cases 
of paralysis of the excitomotory function (§ 144.) the result may be 
caused by suspended function, either of the nervous centre, (medulla 
oblongata,) of the afferent nerves (par vagum and sympathetic,) or of 
the efferent nerves (phrenic, intercostals, and spinal accessory,) which 
complete the respiratory circle. Amongst influences which destroy 
the function of the medulla oblongata itself, may be mentioned, he- 
morrhagic effusion into or upon the medullary substance, fractures of 
the base of the skull, and any very considerable pressure on the whole 
encephalon. I have witnessed several deaths from encephalic he- 
morrhage, in which the stroke was not attended with complete loss of 
consciousness, and could not therefore be termed apoplectic; it was 
simply paralytic, with loss of power of articulation, with hemiplegia, 
and with laborious and stertorous breathing: this latter condition ex- 
citing voluntary efforts or struggles, the patient by gesticulations, and 
violent gaspings, showing his consciousness of the failing respiration. 
In two such cases, in addition to some hemorrhage into one hemisphere 
of the brain, there was a clot in the pons Varolii. Instances of 
this kind establish the truth of the distinction between the death by 
coma and death by paralysis. Some poisons affect the spinal medulla 
more immediately than the brain. Thus, animals poisoned with woo- 
rara, essential oil of bitter almonds, conia, belladonna, and perhaps 
other agents, are affected with gaspings and other signs of impaired 
function of respiration before they lose consciousness ; according to 
the experiments of Sir B. Brodie and others, they die simply from the 
suspension of respiration, and if this process be artificially maintained 
for a time, they may possibly recover from the effects of the poison. 
The same remark applies in a degree to opium and its active principle, 
but less forcibly; for these induce coma early, and often impair the ac- 
tion of the heart also. Experiments are wanting to establish the ele- 
mentary operation of this and other poisons, and to connect the same 
with the views physiologists now hold regarding the several functions. 
In some cases in which animals have died under my observation, from 



DEATH IN TTIE MEDULLA. 



447 



rapid hemorrhage, the respiration has ceased for some seconds before 
the heart's action ; and from the peculiarly laboured state of the breath- 
ing, and late retention of consciousness, I have been induced to con- 
clude that death from hemorrhage, in some instances at least, is due 
to suspension of the functions of the spinal medulla. 

630. The division of the eighth pair of nerves in the neck of animals 
illustrates one mode by "which paralysis induces death. These are the 
chief incident or afferent nerves that run from the lungs to the spinal 
medulla, and that transmit the impressions whereby the motory nerves 
of the muscles of respiration are excited. When they are divided, the 
breathing is imperfectly performed, and expectoration and cough can- 
not take place; apnoea, therefore, gradually follows. Although dis- 
ease does not exhibit precisely the same result, yet an approach to it 
is seen in the dyspnoea, sometimes constant, sometimes in paroxysms, 
which the pressure of tumours on these nerves, or malignant disorder 
involving their structure, causes. 

631. The third mode in which the nervous link of respiration may 
be broken, through injury of the excitomotory column of the spinal 
marrow or its branches, is exemplified when the neck is broken, or the 
upper cervical vertebras are dislocated. Pithing an animal acts in the 
same way. All parts supplied by nerves from below the injured por- 
tion of the medulla become paralyzed, and therefore their motions 
cease. Diseases in the vertebras, in the spinal cord, or in its mem- 
branes, have been followed by similar results; and the functions of the 
several nerves of respiration are illustrated by these cases. I have 
known disorder affecting the cord at the upper cervical vertebras to 
cause loss of motion in all parts below the neck except the diaphragm, 
which is supplied by the phrenic nerve ; the respiration w r as for awhile 
entirely carried on through it. The patient afterwards regained power 
in the spinal accessory nerve, and was able to elevate the upper part 
of the chest; and subsequently the superior intercostal nerves and 
muscles resumed their functions for a time. 1 In other cases, disease 
of the spinal cord creeps from below upwards ; there is then first para- 
lysis of the lower extremities and pelvis, next of the intercostal mus- 
cles, and at last of the neck. The advance or retrogression of these 
symptoms is of great importance in the prognosis of such diseases. 

632. The functions connected with excretion are also dependent on 
the integrity of the spinal cord ; they fail when it is seriously injured, 
and the failure may furnish indications of death, beginning at this organ. 
When the cord is affected only at a point, and remains healthy above 
and below it, the mischief may merely intercept the transmission of sensa- 
tion upwards, or of volition downwards, beyond the injured part. Hence, 
there may be loss of sensation, or of voluntary motion, or of both, in 
the lower portions of the body. If the paralysis reach the urinary ap- 
paratus, the power of spontaneously voiding urine is lost. But the re- 
flex or independent excitomotory influence of the spinal cord remains, 
the sphincters and the bladder retain their power, and when the ca- 
theter is introduced into the latter, it contracts as usual, aided by the 



1 Med. Chir. Trans., 1843. 



448 



PKOGNOSIS — MODES OE DEATH. 



voluntary action of the diaphragm and abdominal muscles. It has 
been before noticed (§ 149,) that under these circumstances the mus- 
cles of the lower extremities retain and accumulate their irritability, 
and although the will has no command over them, tickling or even 
touching them, excites them to contract with unwonted energy (§ 141.) 
The exercise thus incidentally induced seems to be sufficient to pre- 
serve their nutrition, for they do not waste away. 

But the matter is altogether different when the spinal cord is exten- 
sively injured, by crushing, softening, or by a considerable effusion of 
blood or pus into its sheath. Its function then ceases, not only as a 
communicator of sensation and voluntary power to the lower parts of 
the body, but also as an originator of that involuntary excitomotory 
power by which the sphincters contract and the urinary bladder eva- 
cuates its contents. Hence, there is a constant dribbling of urine, yet 
without the power completely to empty the bladder. The feces are 
discharged unconsciously, and without control. The limbs are not 
only insensible and inobedient to the will, but their muscles can no 
longer be excited by tickling: they lose all capacity for motion, and 
the blood-vessels are devoid of the influences which nerves of all orders 
exercise upon them. It is not surprising, under such circumstances, 
that the death which has begun in the spinal cord should spread to 
the parts whose functions that organ can no longer maintain. The 
urine, imperfectly discharged, putrifies, and causes inflammation of the 
bladder, which may gradually extend to, and stop the secreting opera- 
tions of, the kidneys. The intestines become distended and obstructed 
with gas and pent up feces. The proper circulation of the limbs fails 
for want of due movement and nervous influence in and upon the mus- 
cles and vessels ; their nutrition ceases, they become ©edematous, par- 
tially inflamed, livid, and at length gangrenous: all these changes are 
so many signs of the progress of death which has begun in the spinal 
cord. 

From the remarkable effect of cold and particular poisons on some 
of the lower animals, inducing, as they do, paralysis of the hinder ex- 
tremities, it is probable that these agents operate injuriously principally 
by affecting the function of the spinal cord, beginning with the part 
most remote from the sensorium. Is the gangrene of the lower extre- 
mities, sometimes induced by the use of ergotted corn, in any way 
connected with injured function of the spinal cord? 

Death of the spinal medulla supervenes on that beginning with coma 
and asthenia in many cases; and as the involuntary excitomotory func- 
tion of this organ is the maintainer of many processes essential to life, 
the symptoms dependent upon its derangements are of great importance 
in connexion with prognosis. (See § 154.) 

633. JSfecrwmia, or death beginning with the blood, is a term which 
I venture to give to those fatal cases where the chief and most remark- 
able change is exhibited by the blood. In typhoid fevers, and other 
analogous malignant or pestilential disorders (§ 105,) none of the solids 
of the body exhibit invariably such an early change of function or of 
structure as warrants the tracing of death to them. It is true, that 



NECRiEMrA — DEATH OF THE BLOOD. 



449 



the offices of many solid textures are impaired — the muscular and ner- 
vous systems, secretion, digestion, assimilation, and nutrition, all suf- 
fer ; but the very universality of the affection seems itself to point to 
some more general cause, as the ultimate seat of the mischief, that can 
be found in any individual function ; and such a cause may be found in 
the blood. This liquid, at an early period of these diseases, when they 
occur in their worst form, exhibits changes which show that disorder 
begins in it, and this disorder may reach to a fatal degree. The ap- 
pearance of petechire and vibices on the external surface, the occurrence 
of more extensive hemorrhages in internal parts, the general fluidity 
of the blood (§ 196,) and. frequently its unusually dark or otherwise 
altered aspect (§ 186,) its poisonous properties as exhibited in its dele- 
terious operation on other animals (§ 259,) and its proneness to pass 
into decomposition, point out that the circulating fluid is the essential 
seat of disorder; and the failure of its natural properties as the vivifier 
of all organs and functions (§ 182, 263,) is plainly the mode by which 
death begins in the body. How far the change is in the structure 
(§ 189) and vital properties (§ 211,) or in the chemical composition of 
the blood (§ 181,) farther research alone can determine; the vivifying 
power of the blood depends on all these together, and it is manifestly 
this which fails. Hence the complete adynamia, or general prostra- 
tion of vitality which occurs where this cause of death is most energe- 
tically operative. The blood, the natural source of life to the whole 
body,, is itself dead, and spreads death through the frame instead of 
life. Almost simultaneously, the heart loses its power, the pulse be- 
coming very weak, frequent, and unsteady; the vessels are deprived of 
their tone, especially the capillaries of the most vascular organs, and 
congestions occur to a great extent (§ 290, 293:) the brain becomes 
inactive, and stupor ensues; the spinal medulla is torpid, and the 
powers of respiration and excretion are imperfect; voluntary motion 
is almost suspended ; the secretions fail ; molecular nutrition ceases; 
and at a rate much more speedy than in other modes, molecular death 
follows on somatic death — structures die and begin to run into decom- 
position as soon as the pulse and breath are suspended; nay, a partial 
change of this kind occasionally even precedes the death of the whole 
body (somatic death — Dr. Pritchard, 1 ) the fetid aphthous patches in the 
throat, and the offensive colliquative diarrhoea of persons in the last 
stage of various fatal diseases ; parts running into gangrene, as in- 
stanced in the carbuncle of plague, the sphacelous throat of malignant 
scarlatina, and the sloughy sores of the worst forms of typhus, and in 
the large intestines in dysentery, the putrid odour exhaled even before 
death 2 by the bodies of those who are the victims of certain pestilential 

1 See Dr. Symond's interesting essay on "Death," in the Cyclopaedia of xlnatomy and 
Physiology. 

2 Certain anecdotes usually considered to be superstitious, derive some degree of pro- 
bability from, the above considerations. It is said that some of the lower animals, espe- 
cially dogs and rats, have an instinctive foreknowledge of the approach of death in a 
house. I have known two instances, in which for two clays before a death, and subse- 
quently until the body was removed from the house, rats from the drains infested the 
basement of the house to a degree never approached before or since. It is possible that 
a deathy odour (of which some sensitive persons profess themselves to be conscious) may 

29 



450 PROGNOSIS — MODES OF DEATH. 

diseases, — these are all so many proofs of the premature triumph of 
dead over vital chemistry. 

634-. The above illustration is an extreme case; but there are many 
other instances of a slighter kind in which disease begins with the blood, 
and in which various disturbances and reactions result. The agents 
which appear thus primarily to affect the blood in an injurious way, 
are especially the endemic, epidemic, and infectious influences (§ 81, 
88, 93,) animal and vegetable poisons, like that of the most venomous 
reptiles and certain fungi, and probably some minerals, such as sul- 
phuretted hydrogen, selenium, and, in part of its operation, arsenic. 
The direct influence of all these agents is depressing (§ 105.) and when 
they act in large quantities, or in a concentrated form, the vital powers 
fall quickly into a state of adynamia or prostration, which soon issues 
in death, after the manner which has been already described, the blood 
having first invariably manifested a change. But if the noxious in- 
fluence is in smaller quantity, or in a more diluted condition, the vital 
powers react against it (§ 16) in various ways, the object of the reac- 
tion mostly being its expulsion from the system. The shivering, hot 
stage, and sweating termination, of paroxysms of intermittent fever; 
the analogous, although less marked series of febrile derangements 
which occur in slight forms of remittent and continued fevers; the pro- 
fuse and violent fluxes from the stomach and intestines in cholera, dy- 
sentery, and epidemic diarrhoea, and the somewhat similar discharges 
induced by poisonous ingesta, are all instances of vital reaction at- 
tempting the expulsion of noxious matter and of some part of the ani- 
mal fluids corrupted thereby. But these struggles frequently consti- 
tute serious diseases, in which life may be compromised as much by 
the violence and exhausting effect of the reaction, as by the prostrating 
influence of the cause of the disease: in these more complex affections, 
individual organs suffer especially in different cases, and the danger 
and cause of death may exist less in the changed condition of the blood 
than in the results thus induced, or the exhaustion secondarily conse- 
quent upon them, so that death ultimately takes place, not by neerae- 
mia, but by coma, asphyxia, or asthenia, modes of death already con- 
sidered. 

635. The injurious effect of these poisons may be still more com- 
pletely prevented when their quantity is small and the living powers 
are vigorous. A diarrhoea, a profuse sweat, or a free flow of urine, 
sometimes carries off the commencing disease. The intestines, the 
skin, and the kidneys, appear to be the proper emunctories through 
which morbid matter is expelled. The peculiar fcetor of the secretions 
from the bowels in typhoid fever ; the beneficial influence of moderate 
diarrhoea, in the early stage of fever ; and the appearance of a foul 
fibrinous substance (typhus material, of German writers.) in the intes- 
tinal glands in typhus, all seem to be examples of the elimination of a 

be perceptible to the acute olfactory organs of these animals: or perhaps a more sub- 
stantial cause of attraction may be presented in the putrid excrementitious discharges 
commonly thrown down the drains under these circumstances: some countenance is 
afforded upon the same principle to the still more marvellous assertions generally made 
by sailors, that sharks pertinaciously follow a ship that bears a dying man or corpse. 



DEATH OF TITE BLOOD — NECRiEMIA. 



451 



morbific matter. It has been already suggested (§ 404, note) that the 
frequent follicular inflammation, ulceration, and sloughing of the in- 
testines in fever, may arise from the excessive irritation of the se- 
creting follicles during the exercise of this their eliminating function. 
Again, it has been mentioned, that granular degeneration of the kid- 
neys, which impairs the eliminating power of these organs, renders the 
body peculiarly liable to contract epidemic and infectious diseases, and 
to succumb under them (§ 260. ^ On this account the prognosis of 
these cases is unusually unfavourable. These remarks apply equally 
to persons who have been habitually intemperate. On the other hand, 
those whose kidneys are naturally very active, resist disease more ef- 
fectually, and throw off its effects more readily (§ 448.) In like man- 
ner, it is well known that patients with an habitually dry skin do not 
get rid of a fever so easily as those in whom perspiration is readily 
excited. 

686. Besides these influences introduced from without (§ 634,) which 
attack the blood first, and in extreme cases injure its composition and 
cause its death, there are others of like nature, but which originate in 
the body itself. Thus the processes of gangrene and suppuration oc- 
casionally infect the blood with a septic poison (§ 470, 475,) and cause 
death much in the same way as the disorders alluded to. The sudden 
suppression of the excretions of urine or bile, by disease, or by the in- 
fluence of any severe shock, also seems in some cases to operate by in- 
juring the properties of the blood; whilst in other instances it distinctly 
induces coma or asthenia. The retention of excrementitious matter 
has been elsewhere adverted to as a cause of caclisemia, or depraved 
state of the blood (§ 249, 564 ;) it is the same occurrence in an extreme 
degree, that sometimes causes necrssmia, or death of the blood. 

637. The symptoms which should awake suspicion of the approach 
of death by necramiia may be gathered from the preceding descriptions. 
They are generally called typhoid, putrid, or malignant. For example : 
a congested appearance of the whole surface, the colour being dusky 
or livid, and extending to the conjunctiva, tongue, and fauces: various 
slight exanthematous or papular patches on the skin, often with pete- 
chia ; more extensive hemorrhages in form of ecchymoses, or oozing of 
thin bloody fluid from the gums, nostrils, and sometimes from other 
passages; extreme prostration of strength, with an obtuse state of all 
the senses and mental faculties, occasionally combined with delirium 
and twitchings of the limbs ; half-closed eyes and dilated pupils ; a very 
quick, weak, and soft pulse; frequent and unequal respiration; absence 
of appetite; intense thirst; a dry, brown tongue, with dark sordes on 
the lips and teeth ; a progressive fall of temperature, from the first fe- 
brile elevation ; cold, clammy, and fetid perspiration ; hiccup ; subsultus 
tendinum ; scanty, offensive urine ; involuntary discharges. 

Some diseases of the same class are modified by peculiar circum- 
stances. Thus in malignant cholera, excessive discharges of serum, 

1 This was well exemplified in the case of an epidemic erysipelatous angina, which 
attacked several patients of the University College Hospital in the Spring of 1843. About 
a dozen persons suffering from other diseases, were affected; of these three died from 
the erysipelas extending to the larynx, and in all these the kidneys were granular and 
the urine albuminous. 



452 



PROGNOSIS — MODES OF DEATH. 



by vomiting and by stool, render the blood so thick that it can no 
longer circulate through the vessels ; the pulse then ceases, and the 
surface becomes blue and cold from the darkness and stagnation of the 
blood, and shrunk from the exhaustion of its fluid. In yellow fever, 
altered blood is ejected from the stomach in the form of what is called 
black vomit. But this subject belongs properly to special rather than 
to general pathology. 

638. It has been stated, that the perfect distinction of these dif- 
ferent modes of death is almost exclusively confined to cases where the 
dissolution is speedy or sudden. In the slower process by which dis- 
eases generally prove fatal, all functions and structures are more or 
less involved; and the life in all is then dwindled down to so slight a 
thread, that when it breaks in one, it is so immediately afterwards lost 
to the rest, that it is exceedingly difficult to determine where the dis- 
ruption has first taken place. 



453 



CHAPTER YII. 
■ 

PROPHYLAXIS AND HYGIENICS. 

639. Prophylaxis treats of the means by which particular diseases 
can be guarded against ; hygienics relate to the prevention of diseases 
in general, or, in other words, to the preservation of health. The 
former is connected with special rather than with general pathology; 
and is rationally founded on a due knowledge of the causes, nature, 
and tendencies of disorders, and of the various circumstances in regard 
to diet, regimen, residence, and medicine, which are capable of re- 
moving the causes, or of counteracting their operation. 

640. Hygienics 1 consist of the knowledge and application of the 
means, by which the structures and functions of the body may be kept 
in that normal state which conduces to their continued welfare, — that 
is, in health (§ 6.) It has been seen, that both structures and func- 
tions have the elements of disease in themselves, when anything dis- 
turbs their due relations. The circumstances which lead to such dis- 
turbance, have been noticed both in connexion with the causes of 
disease (under the head Etiology,) and in connexion with its intimate 
nature (in the division Pathology proper ;) and remarks on the medi- 
cinal and other influences whereby such circumstances may be prevented 
or counteracted were introduced in the context to a sufficient extent 
to have served to suggest the'principles of hygienics. It will therefore 
be sufficient in this place to consider briefly the principal matters which 
are concerned in the maintenance of health, and these may be arranged 
under the following heads :— Food; Clothing; Temperature; Airy- 
Exercise; Mental Occupation ; Sleep and Excretion. The nature of 
the work precludes the possibility of dwelling upon the details of these 
important topics ; and the following is intended as a mere outline in 
conformity with the principles principally explained. 

FOOD. 

641. The object of food being the supply of materials, which after 
preparation by the process of digestion, shall repair the waste of the 
body and maintain its temperature, it is obvious that the purpose will 
be best effected when the supply is of such quality and quantity, and 
so administered, as to suit respectively the powers of digestion and 
the wants of the system for nourishment and warmth ; in other words, 
food should be digestible, nutritious, and califacient, and the articles 
which duly comprise all these qualities will be the most wholesome 
food. 

642. The importance of a due combination of the chief alimentary 

1 I use this term (derived from the Greek vyieinnoq, relating to health, and analogous 
to optics, acoustics, &c.) as more conformable to our language than the French term 
hygiene. 



454 



HYGIENICS. 



principles, albumen, oil, and sugar or starch, with water as their diluent, 
in substances employed as food, has been pointed out (§ 58 ;) and the 
expediency of selecting such materials as comprise these in the best 
quality or condition, may also be inferred from preceding observations 
(§ 60.) But it will hardly be superfluous if the subject is further il- 
lustrated by a few comments oa common articles of diet. 

Wheaten bread comprehends the albuminous (gluten) and the amy- 
laceous principles, and it only needs the addition of butter to complete 
the requisite combination for moderate nutrition. The goodness of 
bread depends not only on the character of the grain from which the 
flour is obtained, but also on the mode and degree of its fermentation 
and baking. If fermented with leaven instead of yeast, or if over- 
fermented, acetic acid is generated, and the bread becomes sour ; this 
is the common fault of bread in large towns where the supply of yeast 
is insufficient, and it prevails generally on the continent. The evil is 
avoided in the unfermented bread, which is rendered porous by an ef- 
fervescence of carbonic acid gas, caused by an admixture of carbonate 
of soda with the flour, and hydrochloric acid with the water, with which 
the dough is made ; when well prepared such bread is very sweet and 
free from acidity, but unless carefully manufactured it is liable to be 
heavy, and, like imperfectly fermented bread, it is then unfit for mas- 
tication. Bread insufficiently baked is glutinous and indigestible, and 
so also is quite new bread which has not dispersed its moisture. These 
defects may in a great measure be remedied by toasting it in thin slices ; 
this expedient has also the advantage of dispersing much of the acid 
from sour bread. Very white bread is objectionable as being less nutri- 
tious (having less gluten) and more constipating than that made with 
less refined flour: but the coarse material commonly sold as brown 
bread errs to the opposite extreme, from containing a bran that is 
coarse enough to be irritating to many stomachs. Good country bread 
fermented with yeast, and well baked, is the kind most generally 
wholesome. 

Meat comprises in itself the albuminous, oily, and gelatinous prin- 
ciples, besides creatine and other soluble extractive matters, also pro- 
bably nutritious. It needs to be combined with vegetables or bread 
to make it agreeable to the palate and stomach. The object in keep- 
ing and cooking meat is to render it so tender that it may be easily 
softened by the gastric juice, and all processes which interfere with or 
go beyond this result, render it less wholesome. Thus salting, pickling, 
hanging until it becomes tainted, and hardening by over-cooking or 
fast boiling, which corrugates and toughens the fibre, are so many 
ways of spoiling meat for the purposes of digestion, and rendering 
much of its nutriment unavailable. The flesh of young adult animals 
presents the greatest amount of fibrinous material; that of younger 
animals contains more gelatine and fat ; and that of very old ones is 
tough from the prevalence of more condensed fibrous textures, which 
however are converted into gelatine by boiling, and are therefore use- 
ful for the formation of soups. Different kinds of animal food vary 
much in their composition, even when the lean parts only are selected. 
Thus beef and pork contain a large proportion of fat; mutton has 



FOOD — PLAN OE DIET. 



455 



somewhat less; and in the flesh of fowl, game, and white fish, there 
is only a very small amount. This affords an explanation of the fact 
that the latter articles make the best food for persons of weak stomach. 
But the proportion of creatine and coloured extractive matter doubt- 
less also has to do with the quality of the food ; thus the flesh of hare, 
which contains much of these constituents, is more heating than that 
of chicken and whiting or sole, which may be taken to be the types of 
the mildest form of solid animal nourishment. The lean of veal con- 
tains very little fat; and is therefore not objectionable on account of 
its richness ; but it often disagrees, probably in consequence of the 
calves being so much drained of blood before they are killed, that the 
muscular acids predominate. Veal w T ell stewed with rice is less un- 
wholesome than in other modes of cooking. Soups and broths, when 
deprived of excess of fat, are very useful articles of nourishment used 
as auxiliaries to solid food, but they are not substantial enough to sup- 
ply a meal to a healthy person. Eggs and milk, separately or com- 
bined, form light and nutritious articles of diet. They are rendered 
easier of digestion by being heated to about 180°, by which part of 
the albumen is slightly coagulated. Both eggs and milk contain a 
considerable amount of oil, w r hich causes them, when taken too freely, 
to disagree with persons of bilious habit. They are also prone to 
speedy decay, and lose much of their wholesomeness, even in a day or 
two. Fresh butter is an excellent adjunct to bread and vegetable sub- 
stances; but it likewise soon becomes rancid and loses its salubrious 
properties. Cheese is a low form of a protein compound, and requires 
energetic digestive and assimilating powers to raise it to the higher 
standard of the material of the blood-plasma, and being unassimilated, 
it tends to increase the lithic acid in the blood, and to promote gouty 
and kindred disorders ; it is therefore wholly unfit to be used as food 
by delicate persons, and those of weak digestion. 

Oleraceous and succulent vegetables and fruit are fit adjuncts to the 
more nutritious articles of food, which they serve to dilute, and by the 
subacid and extractive matter which they contain, they promote the 
secretions, and thus tend to purify and cool the blood. But, except- 
ing in the case of perfectly ripe fruit and salad, they require to be 
thoroughly cooked, in order to give them the state of softness favour- 
able to the digestive process. 

643. The selection of the articles employed as food, and the arrange- 
ment of the hours for the different meals, must vary considerably with 
the habits and occupations, as well as with the strength and tastes of 
individuals ; but the following plan of diet, with occasional slight mo- 
difications, will be found suitable for most healthy adults. 

Breakfast at from eight to nine, A. M., of bread or dry toast with a 
moderate quantity of butter. One or two new-laid eggs, boiled three 
minutes and a half ; or a little cold chicken or game, or even a mutton 
chop, may be added for those who use much bodily exertion. Beve- 
rage, one breakfast-cupful of cafe au lait; that is, clear strong infusion 
of coffee with scalded milk, in the proportion of one-third of the 
former to two-thirds of the latter. Cocoa deprived of its oil, or thin 
chocolate with milk may be substituted for the coffee, if preferred. 



456 



HYGIENICS — FOOD. 



Luncheon, at from one to two, P. M., may consist of a small basin of 
good shin of beef soup, with vermicelli, rice, or toasted bread in it. 
If meat have been taken at breakfast, a biscuit or piece of bread and 
butter, or small sandwich may suffice for luncheon; wine and malt li- 
quors are generally better avoided at this time. 

Dinner at from five to seven, p. M. (The latter hour is not recom- 
mended, but is often unavoidable.) Wholesome fresh meat and vege- 
tables, well but plainly cooked, served hot, carefully proportioned, and 
properly masticated ; these should be varied from day to day, with oc- 
casional additions of fish, and moderate quantities of farinaceous or 
fruit puddings. Highly seasoned dishes, pickles, salt and dried meats, 
rich and heavy pastry, and cheese, should be excluded from tables aim- 
ing at wholesomeness. Beverages: — sound white wine, (sherry or good 
Marsala, from one to three glasses,) which it is advisable to mix with 
water; or good Sauterne or Moselle unmixed. Those who use much 
exercise may safely substitute malt liquor, bitter ale being the lightest, 
and porter or stout the more sustaining. Half a pint is generally as 
much as is well for health. Many thrive, especially in the country, 
without any fermented liquor. If simple water be taken, it should be 
in moderation, otherwise it may interrupt digestion. Some find warm 
water, or milk and water, a pleasant beverage. The habit of taking 
wine after dinner is one of luxury, not of health, and all that can be 
said of it in a hygienic sense, is — the less the better. The practice 
of making a slight dessert of fruit is not equally hurtful, provided its 
quality or quantity be not such as to excite indigestion. 

Tea. The English custom of taking tea, or a simple warm liquid 
meal three or four hours after dinner is a very salutary one, and pro- 
bably disagrees only with those who dine too late or overload the 
stomach at dinner. The warm liquid assists the separation and ab- 
sorption of the chyle from the chyme which is effected at this period. 
But it is obvious that the introduction of solid food into the stomach 
with it must interfere with this process ; therefore little or nothing 
should be eaten — certainly not quantities of buttered toast and rich 
cake. Two or three moderate cups of black tea with a little milk and 
sugar, form a salutary and agreeable wash for the stomach, and serve 
to remove all acrid materials, left undissolved by digestion, and which if 
not carried away might disturb that rest, for which the appropriate hour 
now approaches. It may be added that tea is nutritious in a degree, 
as well as a diluent. Liebig has shown that its peculiar constituent, 
theine, is an azotized principle of a highly plastic nature, and chemi- 
cally almost identical with the analogous principle of coffee (caffeine.) 
The observations of Dr. Bocker further show that both tea and coffee 
retard the destruction and waste of the tissues of the body; so that 
by their aid a person can subsist on less food without losing weight, 
than one who drinks water only. This accounts for the well-known 
invigorating and refreshing influence of tea and coffee. 

644. The practice of dining early, at from one to three P. M., which 
is pursued by the majority of persons in the lower and middle ranks of 
society, would deserve more general adoption on the score of health, 
were it not generally impossible then to devote the time to it, and to 



ARRANGEMENT OP MEALS. 



45T 



rest after it, that the principal meal requires. A hurried early dinner, 
if plentiful enough to satisfy the appetite, is pretty sure to cause indi- 
gestion, and disqualifies for exertion afterwards. If, on the other hand, 
it he purposely made light to avoid this, it may not suffice for the wants 
of the system, and so an evening meal or supper becomes necessary. 
The chief objection to suppers is that they are indulged in either so 
freely or at so la te an hour, that primary digestion is not accomplished 
by bed-time. Hence flatus and other symptoms of indigestion occur 
on lying down, and prevent or disturb sleep, and the individual rises 
on the following morning with, a pasty mouth and unrefreshed. To 
avoid these consequences, the supper should be taken at least two hours 
before going to bed ; and should consist of such light materials as are 
easy of digestion, not too bulky, and not disposed to generate flatus. 
Those who use much exercise may take with advantage a little light 
meat, chicken, game, white fish, or eggs, with a small quantity of wine 
and water, or sound beer (if this do not disagree.) Those who require 
less sustaining food, as for instance sedentary, plethoric, or inflamma- 
tory individuals, will find a more suitable supper in a light farinaceous 
pudding, bread and milk, or oatmeal porridge ; the last is especially 
useful in persons of costive habit. A few currants, raisins, or a little 
apple added to farinaceous puddings serve to counteract their consti- 
pating tendency. 

Regularity in the hour of the meals is of great importance to the 
preservation of health. The stomach acquires the habit of expecting, 
and the power of digesting food at regular intervals, and various dis- 
turbances in its function and in the system result if it be disappointed. 
For this reason it is best for those who cannot always dine early, to 
keep regularly at the late hour. The evil effects of long fasting are 
partly dependent on the infraction of this rule; but some of them 
really result from inanition, as has been noticed under the head of 
causes of disease (§ 63.) Few delicate persons can bear much exertion 
of body or mind before breakfast ; the practice of taking an early 
morning walk is only suited to the robust, who have fed largely and 
late on the preceding day. When it is borne in mind that food is in- 
tended not only to support the slow process of nutrition and repara- 
tion of the textures, but also to afford materials for the immediate pro- 
tection of the blood against the chemical influence of the oxygen ab- 
sorbed during respiration, and to guard the stomach against the che- 
mical action of the gastric juice, the injurious tendency of long fasts 
becomes at once apparent, and this tendency is the more marked in 
proportion as small capacity in the digestive power limits the quantity 
of aliment that can be rendered available at any one time. 

CLOTHING. 

645. The acknowledged purpose of clothing, viewed as an influence 
in preserving the health, is to maintain, as far as possible, such an equal 
warmth of the surface and extremities of the body, as may conduce to 
the comfort of the feelings, and may promote a free circulation, per- 
spiration, and innervation in all the external parts of the body. But 
the healthful operation of clothing is not altogether confined to its pro- 



458 



HYGIENICS — CLOTHING. 



perty of retaining warmth. It is useful also in protecting the body 
against the injurious influence of external heat, dryness, moisture, and 
electricity. Various modifications of the clothing serve best to secure 
these ends under different circumstances. 

The lower animals exhibit many interesting facts illustrative of in- 
stinctive or natural provisions for varying their clothing, to suit differ- 
ences in season and weather ; from some of these we may derive useful 
instruction. The change of coat in horses takes place in spring and 
autumn, at times which depend to a great extent on the character of 
the season ; the thick winter coat being slow to come off in a cold 
spring, but being soon shed in continued warm weather : so likewise 
cold weather in the autumn accelerates the thickening of the coat, 
which in horses left to nature we find abundantly provided before the 
severity of the weather is established. Sheep change their wool only 
once in the year; but its rapid increase before the winter sets in, and 
its tardiness in loosening and falling off until June, when all the cold 
winds of the spring have passed by, afford useful suggestions as to the 
propriety of anticipating the cold by the protection of additional dress, 
and of patiently awaiting its subsidence before that protection is laid 
aside. Birds moult their feathers early in the autumn ; the new plume 
then thickens in down as the winter sets in. In the spring many of 
the downy feathers drop off, and are in some tribes appropriated to 
the lining of their nests: through the summer the feathers continue to 
get thinner until the moulting season, when all give place to the new 
plumage in their turn. 

But attentive observation of the appearance and habits of animals 
detects further contrivances whereby the same coat or plumage is 
caused to vary in its protective power with changes of the weather as 
well as of season. Thus cold determines a partial erection (§ 120) of 
hairs and feathers, which has the effect of increasing the thickness of 
the covering which they form, so that this retains more air in its in- 
terstices, to the augmentation of its non-conducting and protective 
power. On the other hand, warmth occasions hairs and plumage to lie 
close and smooth, so that they form a thinner investment, which per- 
mits the more ready escape of heat. Horses, which are exposed in 
the winter, often roll in the dirt and mud, and this concreting in theft 
coats gives them a thickness and capacity to resist the outward pas- 
sage of heat, which it would be unwise to deprive them of by the pro- 
cess of grooming. Hence curried horses require artificial clothing. 
The feathered tribes generally are protected from wet by their imbri- 
cated plumage, which is rendered more effective by the drooping di- 
rection which they give to their feathers and tails when exposed to 
rain. But they are supplied with another means of rendering their 
clothing waterproof, in the oil with which their feathers are imbued. 
In aquatic birds this dressing is so abundantly supplied by the skin 
itself, that the plumage scarcely ever becomes wet. In other families 
there is less fat in the integuments; but the defect is remedied by the 
instrumentality of a large oil gland situated above the tail, and to 
which they instinctively have recourse when pluming and dressing 
their feathers. It is very interesting to observe how domestic poultry 



PROTECTION FROM COLD AND DAMP. 



459 



spend the greater part of a wet day in this occupation of inunction, 
which is no doubt a luxurious as well as a useful one. Another habit, 
contrasted with the preceding, may be noticed in the same birds in 
warm dry weather; that, namely, of throwing dust or ashes into the 
plumage; perhaps the object of this is to remove any superfluity of oil, 
or it may be only to relieve the irritation produced by vermin, with 
which they are always infested. Some land birds, more rationally, 
delight in washing under the same circumstances. 

The preceding facts are not devoid of instruction in regard to the 
management of the dress of human beings, who learn to cover their 
nakedness under the guidance of experience and reason, which are 
better or worse guides than instinct, accordingly as they are well or 
ill employed. It says little for the boasted superiority of man's rea- 
son, if it do not lead him to adopt means more effectual in resisting 
the hurtful action of temperature and external influences than those 
which are matters of instinct with the lower animals ; and yet there 
can be little doubt that none of these suffer from cold, wet, and atmo- 
spheric changes, to the degree that human beings do. This is because 
reason and common sense are too frequently set aside by foolish habits, 
originating in vanity, fashion, caprice, prejudice, indolence, or igno- 
rance, and disease and infirmity are the penalties that are paid for the 
folly. 

The most convenient and concise plan of practically dealing with 
this subject of clothing will be to consider the way in which the phy- 
sical influences that injuriously affect the body may be best intercepted 
by articles of dress. 

646. We guard against external cold, by covering the body with 
such materials as by their low conducting power and thickness prevent 
the undue escape of animal heat. The most effectual for this purpose 
are furs and woollen fabrics ; next rank thick spongy silk and cotton 
stuffs ; and the lowest of all are linen cloth, and silk and cotton webs, 
which when very thin lose nearly all their protective property. The po- 
rosity of furs and woollen garments is also valuable in consequence of 
its permitting the escape of insensible perspiration, and on account of its 
lightness ; but it impairs their protective quality against strong currents 
of cold air, especially if this be either very dry or very damp. Cold 
air in strong motion penetrates woollen stuffs of considerable thickness, 
and carries with it a dry or a damp chill according to its hydrometric 
condition. In this penetration it is probably aided by the law of ga- 
seous diffusion, which comes into play whenever there are different 
amounts of watery vapour in air (§ 72.) This consideration accounts 
very well for the peculiarly chilling influence of a desiccating east 
wind and of a cold fog; the interference of both with the cutaneous 
perspiration, and with the circulation, explains most of their injurious 
operation. The best protection against these agents, is afforded by 
leather or even by the more impervious textures such as India-rubber 
cloth or oil-cloth; but these should not be worn too near the skin, lest 
they should prevent the proper escape of its perspiration, and cause 
an unhealthy dampness of the surface. Chamois leather may be used 
as a waistcoat over one made of flannel; and the still less pervious 



460 



HYGIENICS — CLOTHING. 



textures rnay be employed either in detached pieces, as in the piline 
and India-rubber chest protectors, or loin belts, or as outer garments 
in Mackintosh capes, cloaks, and overalls, but these should be provided 
with ventilating apertures wherever convenient, to permit the free 
escape of the cutaneous exhalations. In this way may be imitated in 
a degree the clothing of birds, which are much exposed in their flight 
to cold winds, damp or dry ; their plumage being porous and downy 
underneath, but denser and impervious externally, whilst the over- 
lapping of their feathers leaves a free escape for the exhalation from 
the skin. A similar advantage is obtained to a smaller extent by 
using several garments of different degrees of permeability, the warm- 
est and most porous being worn next the skin, and the others exter- 
nally; this alternation of successive layers of different qualities in- 
creases the non-conducting properties of clothing, and diminishes the 
penetrative power of cold and damp. There are very few instances 
in which flannel or fleecy hosiery does not form the best under-dress 
during at least eight months in the year in this country, and a thinner 
material of the same kind, or merino (a mixture of wool and cotton,) 
answers very well during the remaining four. The exceptions occur 
with persons of very irritable or relaxed skin, for whom an elastic cot- 
ton or spun silk material is more suitable. Warm under-dresses should 
not be worn in bed, as they then are apt to relax the skin too much, 
and to render it more susceptible to the impressions of cold during the 
exposure of the day. Calico is the best material for the night dress; 
any additional warmth required being afforded by bed-clothes. It is 
of great importance to maintain the warmth of the extremities; there 
are few who can safely dispense with woollen stockings in the winter 
months : and those who are liable to coldness of the feet should also 
wear flannel or merino drawers, and flannel linings to their shoes and 
boots. 

647. Some of the kinds of clothing best suited to protect the body 
from ivet and damp, are such as have already been mentioned as pre- 
venting the penetration of cold winds. For the exclusion of wet they 
should be worn outside of all other clothes, for the sake not only of 
permitting a freer escape of perspiration, but also of excluding mois- 
ture from other parts of the dress, for although the wet may not reach 
the body, its proximity may chill by evaporation. For the same reason 
the cardinal rule of keeping the feet dry is better accomplished by 
outer" coloshes, gutta-percha soles, varnish, and other like expedients, 
than by inside cork soles or oil-silk socks, which allow the leather of 
the boots or shoes to be soaked in wet, and only intercept its contact 
with the foot. 

648. The change from winter to summer clothing should be made 
gradually and with great caution ; and it is better to be tardy than 
hasty in change. The fitting period varies in different seasons, but it 
rarely occurs before the month of May, often not until June ; for al- 
though there may be warm weather earlier, it is generally of brief du- 
ration, and is alternated with bleak winds which render the spring 
months peculiarly trying, and often cause more illness than all the 
continued severity of the winter. Much of this mischief is to be at- 



VARIATIONS FOR SEASON AND AGE. 



461 



tributed to the too early change of dress (§ 645.) The converse rule 
may be applied to the change at the end of the summer ; which is most 
prudently made in anticipation of the permanent cold. Many of the 
autumnal diseases arise from the great variations of temperature that 
then obtain between day and night, and from sudden changes of wind, 
and these take the more effect in consequence of finding the body re- 
laxed by previous heat (§ 25, 81,) and yet protected by only summer 
clothing. 

649. In this country even in summer the clothing is required to 
maintain sufficient warmth, rather than to exclude heat; but it may 
now be reduced to the thinnest and lightest materials, a slight woollen 
or cotton fabric being retained next the skin, to prevent the chilling 
dampness of the linen when wet with perspiration. Frequent changes 
of linen, where practicable, supersede, to a great extent, the need for 
this precaution, and together with free ablution, are very wholesome 
and refreshing during intense heat. Protection against solar heat and 
hot air is best afforded by loose linen vestments of light colour, large 
straw hats, bonnets, veils, and other like expedients, which it is un- 
necessary to particularize. 

650. It is very probable that atmospheric electricity may exert an 
influence on the health, which may be in some degree counteracted by 
modifications of the dress. Thus silk vestments have a considerable 
protective power in consequence of their property of non-conduction ; 
and if worn next the skin, they may possibly excite electrical distur- 
bance, which is supposed by some practitioners to operate as a hygienic 
agent, with persons disposed to rheumatic and nervous diseases. Fur- 
ther careful observations are, however, needed to determine these 
points. 

651. Under particular circumstances or conditions of the system, 
additional warm clothing is necessary; for instance — -in infancy, when 
the calorific power is low ; in old age ; in convalescence from acute dis- 
eases ; during fatigue and other states of weakness ; in organic diseases 
of the heart, when the circulation is feeble ; in case of privation of food ; 
during the operation of purgative or diaphoretic medicines ; and when 
circumstances prevent the use of a proper amount of exercise. Under 
the influence of these conditions, a feeling of chilliness arises, parti- 
cularly on the surface and in the extremities, and this is an indication 
of the need of more clothing ; and if this be put on to prevent the sen- 
sations of cold, it will often counteract such disturbances of the circu- 
lation and internal congestions as the weakened body is liable to at 
the time (§ 79, 292,) which too often lay the foundation of future dis- 
ease. 

No part of the frame requires the protection of clothing so little as 
the head and face. The final cause of the comparative freedom of 
these parts from the bondage of garments is obvious, for unrestricted 
communication with external space is necessary for the senses, breath, 
speech, and nourishment. The physiological reason for the greater 
power of the head to resist cold, may be probably found in the larger 
size and less varying calibre of its blood-vessels (§ 266,) which even 
in weakened states of the circulation supply an amount of blood that 
may cause a sense of heat and fulness when other parts are suffering 



462 



HYGIENICS — CLOTHING, AIR, ETC. 



from the opposite feeling (§ 830, 331.) But even for the head, during 
exposure to the air and during the night, it is expedient to use such 
light covering as may prevent any check to the perspiration of the 
surface, or to the ceruminous secretion in the ears, the proper conti- 
nuance of which is essential for the preservation of hearing. I do not, 
therefore, altogether approve of the favourite modern practice of dis- 
carding nightcaps, and I have known it to induce catarrhal affections 
of the eyes and nose, earache, and deafness. Those who are prone to 
suffer in this way, or from dryness of the scalp, may find much benefit 
from wearing at night an oil-silk cap over a thin nightcap. 

Various other cautions and directions with regard to clothing are 
sufficiently indicated upon principles of common sense — such as the 
frequent changing of garments, especially under ones, for cleanliness 
sake ; the avoidance of all tight ligatures, lacings, or buttonings, which 
can cause improper pressure on any part of the body, and interfere 
with free motion, circulation, and perspiration. The invention of India- 
rubber web and other elastic materials has supplied a valuable means 
(not used so generally as it deserves) of avoiding these evils, and of 
yet maintaining the due apposition and attachment of the various ar- 
ticles of dress. 

AIR AND TEMPERATURE. 

652. The influence of impure air in causing disease has already oc- 
cupied our attention (§ 72, 73:) we now have to specify what are the 
states of the air that are most conducive to health; and inasmuch as 
temperature chiefly operates by being conveyed through the air sur- 
rounding the body, it will be convenient to include a few remarks on 
this topic under the same head. 

The invigorating effect of fresh air may be partly referred to its su- 
perior purity more perfectly adapting it to the work of respiration ; 
but some of its refreshing power is due to a direct influence exercised 
on the nerves and capillaries of the surface of the body, and through 
them on the functions generally. This is exemplified in the reviving 
power which a current of fresh air or fanning exerts over persons in a 
state of faintness, and this result is the more remarkable when the air 
is cool and the body has been previously weakened by heat and con- 
finement, but the long-continued action of a cold current under these 
circumstances is highly hazardous. The less marked, but more en- 
during, benefits of fresh air are experienced in rides, drives, and other 
out-door exercises, passive or active, which are universally acknow- 
ledged to be essential to the maintenance of the bodily health. To 
obtain the greatest amount of good from these airings, it is advisable 
not only to resort to localities where the air is most pure and free from 
contamination, but also to vary its qualities in other respects. Thus 
the inhabitants of valleys derive benefit from the air of hills ; those of 
inland places, from that of the sea; and residents on the sea-coast find 
advantage in drives inland. For a similar reason, great improvement 
often results to the health from continued travelling by land or sea, 
and although this comprises other hygienic influences, besides change 
of air, experienced travellers rarely fail to distinguish this as being of 
sensible efficacy, and exercising a marked effect on the vital functions. 



HEALTHFUL INFLUENCE OF FRESn AIR. 



463 



Similar beneficial results sometimes ensue from gentle and favourable 
changes of weather, which bring altered states of atmosphere even to 
our own homes. It is by no means certain on what physical properties 
depend the all-varying hygienic influences of air in changing weather 
and different localities; but it may be useful to notice somewhat of the 
direct operation upon the body, of the different states of dryness and 
moisture, temperature and 'purity in the air. 

653. A very dry air exerts the physical influence of causing rapid 
evaporation and of exciting a high degree of electric tension ; the re- 
sulting operation on the functions is generally more or less stimulating. 
The tonicity of the textures is usually augmented by it, whilst the 
desiccating, and probably also the electric action of the air on the cu- 
taneous and mucous surfaces, induces an excitement which is beneficial 
in persons of relaxed and leucophlegmatic habit; but which in the ir- 
ritable and sanguine, may lead to inflammation or fever. A very dry 
air, the effect of which is increased both by heat and motion, impairs 
the perspiring power of the sldn, and produces various kinds of cuta- 
neous inflammation, often with the addition of fever and thirst. To a 
moderate extent, and with a mild temperature, dryness of the air is 
salutary, facilitating as it does the purification of the blood in the 
kings (§ 72,) improving the tone of the motor fibre, checking tendencies 
to excessive secretion, and counteracting various septic processes both 
within and without the body, which are promoted by humidity. We 
formerly had occasion to notice that dryness of the air is one of the 
surest safeguards against the activity of miasmatic poisons (§ 83.) An- 
other reason why dry air may be deemed the most healthy, is because 
the injurious operation of dryness can be more efficiently counteracted 
than that of moisture. A judicious use of bathing (warm or cold,) ex- 
ercise and friction, which by inducing gentle sensible perspiration re- 
move the dryness of the skin; the prevention of too rapid an evapora- 
tion from the surface by inunction, emollient applications (especially 
glycerine,) and difficultly pervious coverings, such as oil-silk, and 
leather, applied to parts which suffer, generally succeed in obviating 
its hurtful influences without interfering with its salutary effects. 

Dryness of the air is best secured by connexion with a light porous 
soil, like sand and gravel, into which the water of rain and dew speedily 
sinks deeply ; or with hard rock, from which it drains away or evapo- 
rates. The nature of the subsoil is therefore of the greatest import- 
ance in so far as it determines the character of the air in any locality. 
A declivity, or an undulating surface, and a freedom from dense foliage 
and very luxuriant vegetation, also contribute to the dryness of a 
neighbourhood, and generally thereby to its salubrity. Dryness of 
the air is further, in this hemisphere, associated with the prevalence 
of certain winds, especially those from the east, the aridity of which 
is due not only to the much rarer occurrence of rain whilst they last, 
but also to the smaller proportion of dissolved moisture which they con- 
tain. And because such winds prevail more both as regards strength 
and frequency in the eastern than in the western portion of the British 
Islands, the former have for the most part a drier climate than the 
latter. But easterly winds have other qualities superadded which de- 



464 



HYGIENICS — AIR AND TEMPERATURE. 



tract considerably from their salutary influence on the animal frame, 
and often prove positively injurious. Thus the north-east and due east 
winds are characterized by bleakness and penetrative coldness (§ 646 ;) 
and except in persons whose circulation is naturally strong, and in 
whom this is kept in activity by exercise, their tendency is to check 
the passage of the blood through the surface and mucous membranes, 
and to impair the functions connected therewith. The east wind ge- 
nerally abounds in ozone; and this may be one reason of its irritating 
action on the mucous surfaces. The general objection to exposed si- 
tuations on account of the capricious and changeable character of the 
winds, applies therefore with peculiar force to such positions as have 
an eastern aspect, for there the transition is more than usually sudden 
and extreme on account of the power and bleakness of the returning 
cold. 

The south-east wind is also dry, and in winter and spring differs 
from that which blows more from the north in being of milder tempe- 
rature; but as summer advances it becomes remarkable for its sultry 
and oppressive quality, which in south Europe is expressed in its high- 
est intensity in the sirocco. Much of the overpowering influence of 
this is due to its desiccating qualities, (manifested not only in animals 
by the thirst and feverish dryness of the skin and mouth, but also in 
plants and trees by the drooping of their leaves,) combined with the 
general relaxing agency of heat on the vascular fibre, by which the 
powers of the circulation are enfeebled, and the purifying processes of 
respiration and secretion are more or less impaired. But doubtless 
something of the peculiar effects of a south-east wind is due to electric 
tension ; and in this country their most marked manifestation generally 
precedes the occurrence of a thunder storm ; nor should the fact for- 
merly mentioned be forgotten (§ 92, note) that it is especially during 
the prevalence of this wind that the air becomes surcharged with ani- 
malcule tribes, and that certain epidemic diseases, as for instance Asi- 
atic cholera, and occasionally influenza, make their greatest progress. 

654. A damp or moist air, irrespectively of its temperature, may 
be considered to be lower than dry air in its vivifying power, inasmuch 
as it contains less free oxygen, and has a lower diffusive capacity to 
aid it in pervading the lungs during respiration. The greater facility 
which it affords to processes of decomposition and infection has also to 
be set against its salubrity in other points, besides some particulars in 
which it is contrasted with moderately dry air. "Warm moist air is 
universally relaxing (§ 25, 123,) and excepting in persons of dry skin 
and oveiVbraeed vessels, it is oppressive and debilitating. Under its 
influence, perspiration accumulates on the surface, perpetuating the 
relaxation so long as warmth continues, and chilling and impairing 
the circulation and excretion if cold ensues; the very evaporation 
from the moistened surface, under such circumstances, causes an inju- 
rious chill. Cold damp air, which is proverbially unhealthy, is more 
certainly pernicious, and its disordering action may be in a great mea- 
sure traced to the physical properties whereby it is made to abstract 
heat and electricity, and to check perspiration and assimilation. Hence 
ensue the retention of lactic acid in the circulation, the formation of 



DRYING DAMP AIR — TEMPERATURE. 



465 



oxalic instead of lithic acid, and the imperfect elaboration of the blood- 
plasma; these aberrations from the normal chemistry of the body, 
often manifest themselves in the shape of various diseases of the blood 
and circulation, of which rheumatism, neuralgia, certain cutaneous af- 
fections, cachectic ulcers, tubercles and scrofula, are familiar examples. 

The most common cause of dampness in the air is the retention of 
moisture on or near the surface of the soil, such as occurs in low grounds 
in which clay prevails, in which water accumulates or is imperfectly 
drained off, and in which evaporation is retarded by the shade of thick 
trees, or of high rocks or hills. But independently of soil, a house 
may be damp in its own materials, which from recent construction, or 
from their tendency to attract and precipitate humidity (as is the case 
with limestone or marble,) may constantly impregnate the air with 
moisture. Wet weather and damp winds, such as the south-west, are 
less injurious causes of humidity, because they are less permanent; 
but their influence is often obnoxiously manifest during their continu- 
ance, and always most so in localities that are damp from other causes. 
The air of the sea-side, even on the south-west coast, although gene- 
rally abounding in humidity, is far less injurious than that of damp 
places inland; probably because much of the sedative and chilling- 
operation of the moisture is in this case counteracted by the stimu- 
lating influence of the saline particles that are associated with it. The 
different effect produced by a sea fog, and by a land mist, is familiarly 
known. 

The hygienic directions which are calculated to prove serviceable 
with regard to moist air are chiefly such as relate to protective or 
counteracting influences. Artificial heat is the most convenient and 
efficacious desiccating agent within our reach; and if combined with 
adequate ventilation, it may be made to do much to remedy dampness 
of air within doors, whether arising from the soil or from the building. 
In warm weather, when fires are unpleasant, much unhealthy moisture 
may be removed from the air, by so adjusting the doors and windows, 
or air holes, that ventilation may be secured without opening apertures 
towards the dampest side of the house. In limestone districts, good air 
may be secured by keeping large pans of quick-lime in the apartments, 
especially those of the basement and ground-floor. This expedient, 
for reasons previously mentioned, is also a serviceable precaution 
against malarious and infectious influences ; its utility in preventing 
meat from becoming tainted in a damp larder has long been known. 

Much may often be done to diminish the dampness of clayey and 
marshy soils in the immediate vicinity of dwellings, by adopting an 
efficient system of covered drainage; by effecting the removal of su- 
perfluous trees and shrubs ; and, where practicable, by covering the sur- 
faces which are most constantly wet, with light sand, gravel, brick and 
mortar rubbish, or some similar light and porous material, which is ca- 
pable of forming an artificial superstratum that earn intercept the mois- 
ture of the clamp ground. The insalubrity of many low parts of the 
metropolis, especially in Pimlico and Westminster, has been wonder- 
fully diminished by expedients of this kind. Protection against the 
damp of lime-stone walls of houses is obtained in a similar way by the 
30 



406 



HYGIENICS — WARMTH. 



process of battening, that is, lining the wall with wood and canvass, or 
lath and plaster. The free use of concrete, or of siate or metallic 
plates, in the foundations of houses, so arranged as to prevent the 
rising in the walls of moisture by capillary attraction, should never 
be neglected, particularly in damp localities, where the lower parts of 
the building are likely to be inhabited. 

655. The subject of temperature has been so frequently touched upon 
already, that it would be a work of superfluity to dwell long upon it here. 
The mean temperature that is generally conducive to comfort and health 
is about thirty-five degrees (of Fahrenheit) below the heat of the interior 
of the body: that is 63° ; blood-heat being 98°. It is rarely expedient 
to sustain an artificial temperature higher than this; for the invigo- 
rating properties of the air suffer at more elevated temperatures, so that 
if more warmth is needed than is retained in the body at this point, 
it should be ensured by additional clothing or other means. The ad- 
vantage of keeping the atmosphere of apartments considerably cooler 
than the body itself consists not only in the greater amount of oxygen 
that is then contained in a given bulk, but also in the greater force 
with which the warm foul air of respiration is carried away from the 
breathing passages, and a pure medium supplied to them in consequence 
of the difference of temperature maintaining a current. Overheated 
rooms are peculiarly oppressive, for the converse reason, unless the air 
be continually changed by efficient ventilation; and rooms warmed by 
stoves or heated air, cause a feeling of closeness which does not result 
from open fire-places, because these latter communicate heat chiefly 
by radiation, and leave the atmosphere comparatively cool. The ani- 
mal body being naturally much warmer than the surrounding air, ope- 
rates as a ventilator for itself, by the same consummate adaptation of 
pneumatic laws as that which supplies a flame or fire with a continued 
current of fresh air ; just as a fire burns brighter and clearer in frosty 
weather, so an animal breathes a purer denser air at the same time, 
which if not injurious by its cold, is refreshing and invigorating to the 
body. Not only healthy and robust persons, but also some who are 
asthmatic or otherwise weak in respiratory power, acquire increased 
strength and energy in clear cold weather; and even those, who from 
weakness of circulation cannot resist continued cold, and usually re- 
quire a mild atmosphere around them, are generally refreshed and 
benefited by breathing cold air for short periods, whilst exercise and 
warm clothing protect them against its sedative and chilling effects. 

656. Artificial heat is most needed by young infants and very aged 
persons ; in them the intrinsic calorific power is too low to bear safely 
even the temporary exposure to wintry air, just mentioned as useful to 
some weakly subjects. So, too, those who suffer in the lungs and air 
passages from even brief impressions of cold, which is the case with 
the greater number of pulmonary invalids, should not venture into the 
open air during inclement weather without the protection of a respira- 
tor, which acts as a kind of clothing to the air passages; and although 
it detracts from the refreshing coolness of the open air, it does not 
materially impair its purity. I have also known this instrument to 
prove useful to ansemic subjects and others with low calorific powers, 



VENTILATION — NATURAL AND ARTIFICIAL. 467 

not merely by its protecting the air passages, but also by its retaining 
and economizing heat which is generally expended with the expired 
air. 1 

657. The absolute necessity of maintaining the purity of air that is 
respired, by continual change, has been repeatedly alluded to (§ 72.) 
In cold weather this change is mainly promoted by the difference of 
temperature that exists in the air heated by respiration or by the fire 
of a room, and in that of the external atmosphere ; the increased ven- 
tilation thus insured has been specified as one cause of the more in- 
vigorating properties of the air in winter.. In hot weather, on the 
other hand, and in apartments that are heated by convection, more 
than by radiation, it is necessary to provide means to assist the motion 
of the air. In summer this may usually be effected by opening win- 
dows and doors ; and the close smell which shut-up rooms acquire in 
that season generally suggests this remedy. In India and other hot 
climates, where even the outer air is so hot and still that it supplies no 
movement, machines are used for creating a current of air, and it is 
farther cooled by evaporation from a moist surface. Even the sprink- 
ling of floors and walls with water is useful, not only by cooling the 
air, but also by secondarily promoting its motion. In very sultry 
weather, dining rooms or other apartments may be kept refreshingly 
cool for evening use, by hanging a canvass blind, saturated with water, 
outside of the window, and by keeping it sprinkled from time to time. 

In cold weather some degree of ventilation is necessarily insured by 
the fires employed for warming rooms ; but it is often effected in an 
irregular or insufficient manner; as by draughts of air under doors, 
and through the chinks of floors ; these cause a cold current on the 
feet and lower parts of the body, whilst the head and breathing pas- 
sages, which are above the opening of the fire-places and the set of the 
current, are in a stratum of warm and less pure air. It is quite true 
that by the law of diffusion of gases, as well as by the force of the 
currents, and other accidental disturbances, a change is effected in the 
whole air of a room ; but it is so less completely and rapidly, than is 
desirable for so important a purpose as the constant supply of pure 
air for respiration. To obviate this, various ventilating contrivances 
have been recommended, but none in simplicity and efficacy excel those 
recommended by Dr. Arnott, 2 which not only furnish apertures calcu- 
lated in themselves to promote a continued change of air in the room, 
but by means of a simple self-adjusting valve, prevent the entrance of 

1 Various expedients for retaining the warmth of the breath for the purpose of 
sustaining animal temperature, were long since recommended by Dr. Arnott and others. 
An incident in point, which occurred to myself many years since, may afford a useful hint 
to others in a similar predicament. I had to go a long journey on a cold winter's night ; 
and there being no room inside the mail, I was obliged to ride on the outside, although 
insufficiently clothed for the exposure. Reflecting on the great loss of heat, manifested 
in the steaming breath of myself and fellow-pas-engers, I endeavoured to save a portion 
by entirely covering my head and face with a silk pocket-handkerchief, the lower ends 
of which were closely tucked inside my buttoned coat. The result was an increase of 
warmth, not in the face and chest only, but even in the extremities, more comfortable 
and diffused than an additional great coat could have produced. 

- On the Smokeless Fire-place, Chimney -valves, and other means, old and new, of obtaining 
Healthful Warmth and Ventilation. By Neill Arnott, M.D., F.R.S., &c, 1855. 



468 



HYGIENICS — AIR AXD TEMPERATURE. 



too strong a current, or the passage of one in a wrong direction. For 
perfect ventilation, two apertures (or sets of them) are requisite ; one 
for the admission of fresh air, another for the escape of that which is 
foul. These should be placed at opposite sides of the room, and it is 
generally well that the outlet should be near the ceiling ; it may be made 
into the chimney when a fire is used (a properly arranged valve pre- 
venting the influx of smoke,) or when there is no fire or chimney, through 
the ceiling or roof, or in a top window pane. When the valvular 
opening into the chimney is adopted, it is absolutely essential to its 
proper working, that the throat of the chimney immediately over the 
burning fire should be narrowed far beyond what it usually is, other- 
wise all the air that enters the room by crevices and inlets especially 
provided, will pass through the large channel over the fire, and there 
will be a tendency for more also to find its way in from the chimney 
through the valve ; and this will accordingly be kept close pressed and 
inoperative. The throat of the chimney over the fire, and the valvu- 
lar opening into the chimney, should together only have the same area 
as the sum of the several inlets for fresh air into the room, then the 
air admitted will be fairly divided between the two outward routes. 
When this arrangement is properly adjusted, the valve will be kept 
constantly pressed back by a steady current passing onwards into the 
chimney for hours at a time, without the slightest attempt at regurgi- 
tation being made. The most suitable position to afford the freest in- 
flux of air, is near the floor; but apertures in this situation are often 
objectionable on account of the chill which is communicated to the 
feet and lower parts of the body. The inlet for fresh air may there- 
fore be conveniently made in the upper pane of a window or the panel 
of a door, where these are as remote as possible from the outlet ; and 
to prevent draughts, and to promote the diffusion of the air through 
the room, the opening should be covered with wire-gauze or a finely per- 
forated zinc plate, in addition to which if necessary, an oblique screen 
of wood or a curtain may be placed before it so as to direct the cur- 
rent to the walls and ceiling. Under these arrangements the fresh air, 
which is heavier, because cooler than that withfn the room, gradually 
falls, and is dispersed, displacing the warmer foul air ; and reaches 
the middle space cool and refreshing for the heads and breaths of the 
inmates, yet causing no draughts on the lower extremities. In very 
cold weather, it is certainly advantageous to have the supply of air 
moderately warmed before it enters the room ; and the best method for 
effecting this, is the employment of a well-regulated warm air or hot 
water stove, or of an Arnott stove, so placed in the hall or at the bot- 
tom of the staircase, that a fresh current may be continually coming 
to it to get heated. This influx of gently warmed air is useful, not 
only by taking off the excessive chill, but also by promoting such a 
free current into the house as serves to supersede those irregular 
draughts, which, in default of other supply, force their way through 
every chink, hole, and cranny in the floors or walls, and which besides 
cold, often bring with them dust and bad effluvia acquired in their 
passage (§ 72, 73.) The extreme dryness of the air thus warmed may 
be obviated by placing shallow earthen pans containing water, on the 
stove. 



MEANS OF WARMTH AND VENTILATION. 



469 



658. The ventilating force that operates in all the above noticed 
cases is that which depends on atmospheric pressure, displacing air ren- 
dered lighter by heat: this force properly applied and directed, amply 
suffices for securing fresh air to ordinary dwellings. But for large 
public buildings in which great numbers of people are congregated, or 
where other causes of contamination or impurity are operative, as in 
manufactories, hospitals, mines, holds of large ships, &c, this force 
may fail to be effectual ; unless when aided by extra fires and lengths 
of chimney, and then much care is required both in construction and 
in management to make it answer the object in view. The new wing 
of the Brompton Hospital is ventilated and partially warmed on a plan 
of this kind, devised and executed by Mr. Haden, of Trowbridge, and 
after more than twelve months' trial it seems to answer very well. The 
other forces which have been applied to effect ventilation on a large 
scale, are mechanical powers, and the operation of a jet of high pres- 
sure steam. The latter is very efficient in creating a strong current 
of air, and is chiefly applicable when foul air is to be drawn off. The 
noise attending it is an objection in some cases. Mechanical ventila- 
tion was for a long time principally effected by the revolving fan wheel; 
but Dr. Arnott has shown that its propelling power is very limited ; 
for when its revolution is resisted by any opposing force equal to the 
pressure of a column of seven inches of water, the motion no longer 
creates an aerial current, but becomes more rapid, and carries the air 
round with the wheel in a sort of eddy, instead of propelling it forward. 
This scientific physician has devised a mechanical ventilating apparatus, 
which in amount and steadiness of power, and of facility with which 
the supply of air can be regulated, excels every contrivance hitherto 
accomplished or proposed. Such a machine, which is a kind of pump, 
moved by water or steam, and which propels air of a regulated tem- 
perature in an accurately measured quantity, has been in use at the 
hospital at York for some years. The chief difficulty in securing its 
successful operation seems to lie in proportioning the propelling force 
to the extent of channels and spaces required to be ventilated. It was 
the impossibility of calculating the latter which appears to have caused 
the failure of a machine of this kind at Brompton Hospital. Dr. Ar- 
nott's plan of mechanical ventilation has been applied with success to 
the supply of pure air in emigrant ships. 

659. But in addition to the supply of fresh air to the interior of 
buildings, certain other measures are often required for the removal of 
contaminating effluvia, especially in large towns. Systematic and 
scrupulous cleanliness, and an adequate and air-tight drainage are most 
effectual for this purpose. Some recommendations with regard to these 
subjects have been already made in treating of exciting causes of dis- 
ease (§ 70 — 73.) For purposes of cleansing, and for rendering habi- 
tations wholesome, an abundant supply of water is necessary; the evils 
of impure air are commonly experienced where this purifying element 
is scanty. Additional means of purification are afforded by certain 
chemical agents possessing the power to absorb or decompose noxious 
effluvia. From the most recent observations, especially those of Dr. 
Stenhouse, recently prepared charcoal appears to be the most efficient 



470 



HYGIENICS — BODILY EXERCISE. 



of these agents, absorbing and destroying all offensive effluvia con- 
tained in the air (§ 105.) Shallow dishes containing the charcoal may 
be conveniently placed wherever a bad odour or effluvium exists; and 
the efficacy of the charcoal may be from time to time renewed by heat- 
ing it to redness under sand. Lime also is a cheap and useful mate- 
rial for the same purpose, and may often be advantageously used both 
by lime-washing walls and ceilings, and by pans of quick-lime kept in 
the basement story of houses near any source of foul air. Other dis- 
infecting agents are still more powerful, and at the head of these un- 
doubtedly stands chlorine, which is invaluable for its efficacy in de- 
stroying noxious effluvia, the source of which cannot be stopped. 
Chloride of lime, and dissolved chlorinated soda, are convenient vehi- 
cles for furnishing a constant moderate supply of the gas, and this 
may be extricated from them in greater quantity by the addition of a 
little acid whenever there is need. A cheaper plan for obtaining an 
abundant supply of the chlorine, is found in mixing black oxide of 
manganese, common salt, and sulphuric acid; the acid being added 
from time to time, in small quantities, throughout the day. 1 Under 
circumstances in which the operation of chlorine is too irritating, nitric 
or acetic acid vapour may be substituted, but they are less effectual, 
and must be used in greater quantities. In houses in which unma- 
nageable drains or immoveable cesspools unavoidably taint the air, 
some of these disinfecting agents should be kept in perpetual opera- 
tion. 2 

BODILY EXERCISE. 

660. The want of exercise has been noticed as both predisposing to, 
and exciting disease (§ 24, 65;) and the opposite extreme, excessive 
exertion, has also been mentioned as equally detrimental in its effect 
on functions and structures (§ 64.) As a hygienic agent, therefore, 
exercise should be between these extremes ; and its utility and impor- 
tance will be proportioned to the regularity and discretion with which 
it is practised. 

Moderate and sustained exercise in healthy air by walking, or riding 
on horseback, and during various out-door occupations and pastimes, ex- 
cites into activity most of the functions of the body, especially the 
circulation and respiration, and those other actions intimately con- 
nected therewith, namely, secretion and the production of animal heat ; 
and, provided the fatigue or exhaustion resulting from the excitement be 
adequately removed by sufficient rest and sustenance, the vital functions 
gradually gain vigour by activity, and the structures concerned in their 
support acquire a fuller and healthier development. The muscles espe- 
cially, including the heart, manifest an increase of strength and firmness ; . 
the blood-vessels are improved in tone, so that they distribute vigorously 
and equalize the flow of blood, and prevent partial congestions and 

1 A cheap and convenient apparatus for fumigating -with these materials has been 
contrived by Mr. Smith, of White Street, Borough, and may be obtained of Home and 
Co., 123, Newgate Street. 

2 The consideration of public sewerage and of other matters connected with these 
topics is far too extensive to be entered on here; but the reader will find much valuable 
information in the various Reports of the Sanitary Commissioners, and of the Health 
Officer of the City of London. 



EXERCISE ADAPTED TO AGE, ETC. 



471 



obstructions; and the blood itself thus energetically carried through 
the organs and textures, undergoes the complete series of changes from 
nutrition, purification, and arterialization, by which its integrity is 
maintained, and by which it is adapted to sustain the several functions 
of the body. The appetite, the digestive powers, the intestinal action, 
the warmth of the surface and extremities, the spirits and temper, are 
generally all improved by habits of regular exercise: — what more 
could be said to recommend any hygienic agent? But since much of 
these beneficial effects depends on the judicious manner in which ex- 
ercise is suited in kind, time, and degree, to the strength, habits, oc- 
cupation, age, sex, and other circumstances of the individual, it may 
be as well to particularize a few cautions and directions in regard to 
the most important of these points. 

661. In childhood, youth, and early maturity, when the joints are 
supple, the textures in full elasticity, and the whole frame fitted for 
quick and varied movements, diversity and activity of muscular action 
are suitable and salutary ; and there is pleasure as well as benefit in 
practising feats of agility and strength, which call into play all the 
muscles of the body, such as running, leaping, climbing, wrestling, 
rowing, and the athletic games of cricket, fives, tennis, quoits, &c. 
But at this youthful age there is less power of enduring continued 
fatigue than in maturer life, and the body more absolutely requires 
repose after exertion. The health of young persons, especially of the 
female sex, is often greatly injured by too long walks, especially if 
frequently repeated, whilst they suffer comparatively little from greater 
exertion for short periods, as in dancing, or riding on horseback. In 
adult age, on the other hand, prolonged steady exertion is better borne 
than exercises requiring great agility of movement; and unless youth- 
ful mobility has been preserved by constant practice, more sober and 
steady motions are more fitting to the sedate age. Exercise on foot 
and on horseback is the ordinary mode, except among the working 
classes, whose occupations engage them of necessity in various kinds 
and degrees of muscular exertion: and in all these experience teaches, 
long before the period of middle age, that more work can be safely 
and comfortably effected by steady and sustained exertions, than by 
sudden or rapid efforts. But it does not therefore follow, that the 
exercise taken for the sake of health in middle age should be monoto- 
nous or slow. Persons who are principally engaged in employments 
either sedentary or confining them within doors with little exertion, 
would feel little benefit or refreshment from the hour or two which 
they can spare for out-of-door exercise, if it w T ere passed in mere saun- 
tering or strolling on some unvaried road. A brisk walk, diversified 
as much as possible in direction, including, if possible, ascents and 
descents, and away from the vicinity of the smoke and effluvia in which 
the rest of the day is spent, and alternated when practicable with an 
inspiriting ride on a free-paced horse, or with active gardening, or 
some like pursuit, will most profitably fill up the time which the middle- 
aged man of business can devote to exercise, and will soon prove itself 
to be a very safe and remunerating investment of such leisure. On 
the other hand, he, who forgetting what becomes his age, relishes no 



472 



HYGIENICS — BODILY EXERCISE. 



exercise but such as is associated with the excitements of the ball-room, 
the cricket ground, the rowing match, or the hunting-field, speculates with 
a capital of mobility and elasticity which he most probably does not 
possess, and although he may sometimes be able to boast of a success- 
ful result, in the recovery of activity and health lost through previous 
habits, he yet encounters a perpetual risk of breaking down under the 
unusual strain to which he subjects his frame, and he gains none of 
that gradual renovation and invigoration which result from more mode- 
rate exercise regularly practised, and varied from day to day. In old 
age the sphere of exertion is still farther limited by functional and 
structural changes that have been already alluded to (§ 48, 546,) and 
exercise, to be salutary, must be still farther restricted in degree and 
variety. Gentle walking or riding on horse-back may be safely prac- 
tised by many, even far advanced in years ; and carriage exercise (such 
as it is, which is scarcely any) remains for the more infirm. The se- 
lection of the particular mode, and the determination of the extent, in 
which exercise may be beneficial in any given case, should depend very 
much on the previous habits as well as on the present condition of the 
individual. If a man has lived a sedentary life, and has become stiff 
and prematurely old in consequence, this is not the time to commence 
habits of activity, which would endanger the integrity of his vegetating 
or mineralized structures (§ 543 — 6.) A similar caution applies to 
those who have lived too fast, and by various excesses and undue ex- 
citement and strains, have exhausted their vital powers and accelerated 
the degenerative changes in their textures: such persons manifest by 
their feeble and tottering gait, and by breathlessness on exertion, an 
inaptitude for exercise, which should be their warrant for not attempt- 
ing it. Carriage airings and gentle frictions of the surface and ex- 
tremities are here the best substitutes. The case is altogether diffe- 
rent with those, who, by a temperate and judicious mode of living, and 
by habits of activity proportioned to their strength and age, have 
economized their vigour, and given fair play to their constitutional 
powers: these may be said to enjoy a green old age, in which moderate 
exercise continues to be not less a source of recreation and comfort, 
than a means of sustaining health: but even these fine, and in all re- 
spects venerable specimens of humanity, sometimes need professional 
warnings against presuming too much on their hitherto well husbanded 
strength. They are often carried off by acute attacks, brought on 
by their stepping out of the sphere of safety, which although wider 
than usual at their time of life, has nevertheless its limits, which the 
steady hand of time is daily narrowing, but in so gradual and imper- 
ceptible a manner, as to escape the attention of their own mental 
powers, now also on the wane. One act of imprudence in advancing 
age may be followed by fatal results; and that may be deemed to be 
imprudent which in any material degree transgresses the bounds of 
accustomed habits. 

662. The periods at which exercise is most salutary, in relation to 
meals, occupation and repose, are commonly those when the bodily 
powers are not depressed by fasting, fatigue, or wakefulness, nor op- 
pressed by the process of digestion. Exercise before breakfast is 



I 

PERIODS FOR EXERCISE. 473 

suitable only to the robust, and those who have fed late and largely 
on the preceding day: delicate persons commonly become faint from 
exercise at this time; and others who do not suffer so far, yet lose a 
portion of the appetency and digestive keenness which render the meal 
agreeable as well as useful, and consequently are more languid during 
the early part of the day. Shortly after breakfast is commonly a very 
good period for exercise: this meal is sufficient to remove the squeam- 
ishness or faintness apt to arise from an empty stomach, yet it is not, 
or should not be, so heavy as to oppress the bodily powers, or prevent 
their capacity for moderate muscular exertion. Those who can com- 
mand the time, will find it advantageous to intersperse their sedentary 
occupations with short periods of exercise, taken if possible in the open 
air; if these be only for ten or fifteen minutes, once or twice in the 
course of the forenoon and afternoon, they will contribute considerably 
to counteract the bad effects of confinement, and by giving a fresh im- 
pulse to the circulation and respiration, will remove congestions, cool 
the head, warm the feet, and thus refresh both body and mind. For 
similar reasons it is well that more extended exercise should be taken 
twice rather than once daily, the second period for it being after an 
early tea, or before a late dinner, according to the arrangements sug- 
gested when speaking of Food (§ 643-4.) Persons whose daily occu- 
pations are fatiguing either to body or mind, and who are obliged to 
dine late, may not have strength sufficient to bear the second exercise 
before dinner; but they may be enabled by an hour or two of rest after 
this meal to take an evening walk, which will then prove to be well- 
timed and refreshing, especially in the summer. Under all circum- 
stances it is of importance to avoid great fatigue both immediately be- * 
fore and after dinner. For this being generally the principal repast, 
needs more than the other meals, the undisturbed energies of the sys- 
tem for its digestion ; and if either the body be exhausted by exertion 
beforehand, or its energies diverted from the digestive organs by ex- 
ercise taken soon after the meal, the digestion will be disturbed, and 
various evil consequences may ensue. It is the chief objection to very 
late dinners, that after the toils of the whole day, the body is too much 
exhausted for the work of digestion, so that stimulants are needed to 
aid in the process, which they can only do irregularly and imperfectly. 

663. The weaker or more delicate the individual is, the more neces- 
sary are the above-mentioned cautions against excessive or ill-timed ex- 
ercise. The interval that should be devoted to bodily recreation varies 
considerably with the strength and habits, and with the kind of exer- 
cise used. Females and delicate persons will rarely benefit by more 
than half an hour or three-quarters of an hour's walk, or double those 
periods of gentle horse exercise : but robust males may find advantage 
in a considerably greater amount. 

664. Exercise varies in effect according to its kind. Walking, 
although it gives some action to most of the muscles of the body, chiefly 
exercises those of the lower extremities ; and by increasing the circu- 
lation and perspiration especially in their direction, it tends to derive 
from the head and chest, and to relieve congestions of those cavities. 
Riding on horseback causes more exertion to the loins, and by the re- 



474 



HYGIENICS — MENTAL OCCUPATION. 



gular movements which it communicates to the viscera of the abdomen, 
pelvis, and thorax, promotes circulation and functional activity in 
them : it is not equally effectual with walking in equalizing the circu- 
lation in the head and extremities, and in cold weather especially it 
often causes headache, but this may generally be prevented by taking 
measures to keep the feet warm. 

Some sorts of exercise which include alternate stooping and raising 
the body, such as are involved in digging and other occupations of the 
garden, are serviceable in promoting the action of the bowels and kid- 
neys; the same remark applies to various games of bowls. Rowing 
has the advantage of very generally and uniformly exercising the mus- 
cles of the whole body; but unless it be practised with moderation, the 
simultaneous pressure which it exerts on every part may prove injurious 
by overstraining the organs of circulation and respiration (§ 64 ;) and 
many instances have come within my observation of the evil conse- 
quences of boat-racing. 

MENTAL OCCUPATION. 

665. Under this head may be comprised a few remarks upon the 
mental influences that are most conducive to the maintenance of health. 
As with the corporeal functions, so with the mental, a moderate and 
equable activity, with some diversity of excitement and relaxation, con- 
tributes to their well-being ; and, inasmuch as the body is greatly under 
the influence of the mind (§ 66,) the health of both is therefore equally 
promoted. The kind and amount of mental exercise that is advisable 
varies according to the different circumstances of age, sex, tempera- 

* Blent, capacity and habit. The topic is indeed far too wide to be com- 
prehended within the very cursory glance that can be given to it here, 
and it must suffice if some of the variations of mental discipline that 
are adapted to these different circumstances are briefly noticed. 

666. In infancy the sentient and perceptive functions are active, 
and the emotional feelings lively, whilst the higher moral and intel- 
lectual faculties are comparatively imperfect. Hence the sensitive ex- 
citability of this age, so frequent a cause of disorder; and which so 
commonly needs to be moderated by various soothing expedients, such 
as gentle and lulling impressions addressed to the senses, and timely re- 
sort to amusing toys and other objects capable of diverting the atten- 
tion and gently exercising the organs of sense and perception. Bat 
as infancy passes into childhood, there is sufficient development of 
moral feeling and understanding to furnish higher powers of control 
and direction ; and although at this age it is equally necessary to avoid 
whatever excites fretfulness and passion, principles of self-control and 
patience should now be carefully inculcated by moral and religious in- 
struction, enforced by the example of consistent kindness and justice 
on the part of those who manage the children. The mental as well as 
the bodily faculties at this early age have no strength of endurance; 
they are soon fatigued ; and nothing can be more hurtful than their 
excitement in too high a degree, or for too long a continuance, by 
games, or scenes of amusement: exhaustion, fretfulness, and bodily 
suffering, are the common consequences of such excesses, and disease 



MENTAL TRAINING — EDUCATION. 



475 



not unfrequently follows. A similar objection may be urged against 
too early or too prolonged attempts to educate the mind : such attempts 
anticipate the period at which it is intended that the power of concen- 
tration and sustained attention should be acquired. Children who are 
precocious in intellect gain this power early, but this is itself a reason 
against intellectual exercises, for it then the more readily tends to 
strain the active faculties to a morbid degree. 

GG7. As the mental capacity becomes enlarged by judicious train- 
ing in ripening youth, it is prepared to grapple with longer and severer 
tasks, and in addition to the direct advantages that result from exer- 
cising the intellect by extended occupation at this age, the indirect 
purpose is also answered of moderating and holding in subjection the 
emotions and animal passions, which now acquire strength. A leading 
rule that should be followed in all attempts to develop and regulate 
the mind, is to employ its several faculties as equally as possible. 
The natural tendency is for those powers which are constitutionally 
the strongest to overrule and weaken the others, and this applies to 
the impulses of moral feeling as much as to intellectual capacity. A 
main purpose of education is therefore to prevent the inequality, by 
exercising the weaker powers and by judiciously restraining those 
which unduly predominate. Herein education includes not merely the 
communication of knowledge, but also the discipline of the heart and 
mind; the subjugation of evil and idle inclinations and propensities, 
and the direction of the attention, or activity of the intellect, to ob- 
jects that are profitable and improving. The influences by whose aid 
such discipline may be exerted are manifold, but they are modified in 
some degree by the age and the character of the individual. In child- 
hood, respect and love towards parents or others exercising authority ; 
in youth, the same feelings confirmed and developed by the convictions 
of the understanding now conferring increased spontaneity of thought; 
and in all ages the constraining and elevating influence of religion, 
which supplies the highest motives and rules for the conduct of think- 
ing and responsible beings; — these are the great leading instruments 
through which mental discipline is to be safely and effectually worked 
out. Other and less dignified motives are often equally powerful, such 
as vanity, pride, ambition, rivalry, and the like; and although these 
mark the falling-off of the human mind from a standard of perfection, 
and if not controlled may become exaggerated into vice, they may 
nevertheless, under proper restraint, be enlisted in the service of mental 
improvement. 

668. When youth ripens into adult age, although technically speak- 
ing, education is then complete, the discipline and culture of the mind 
(which are the objects of education) should still be carried on with an 
energy that is proportioned to the full development which the faculties 
and passions have attained. This being the period at which the au- 
thority of parents or seniors is more or less relaxed, and at which the 
individual becomes of age to take full responsibility on himself, it is 
of the utmost consequence that his mature powers should be directed 
towards a career which will tend to promote his present and perma- 
nent welfare; and much, in regard to his future health, depends on 



476 



HYGIENICS — MENTAL OCCUPATION. 



his then possessing such ascendency of mind over body, of moral over 
animal feelings, as will ensure the establishment of wholesome habits 
of wisdom and temperance. The subjugation of gross appetites; the 
subordination of all turbulent or violent moral or mental emotions; the 
cultivation of the gentle and contemplative feelings best fostered in 
domestic life and in refined social intercourse; and the regular but 
moderate application of the intellectual powers to some definite object 
or set of objects worthy of pursuit; — these are elements of mental dis- 
cipline which become the age of maturity, and if steadily cherished 
cannot fail to conduce, not only to the health and strength of both 
mind and body, but also to enduring comfort and happiness. It is 
true that many difficulties beset the beginner in his endeavours to fol- 
low such rules ; many struggles arise against the inferior part of him- 
self ; much patience and forbearance is called for in regard to others ; 
a constant practice of self-control is demanded in avoiding the temp- 
tations of excitement and intoxicating amusement; and incessant vigi- 
lance over the mind ; to restrain it equally, from wandering into by- 
paths away from its proper road, and from lapsing into desultory ab- 
straction or indolence ; and these impeding forces within, are too often 
prompted or seconded by no less formidable obstacles without, thrown 
up by the multitudinous and ever-rising allurements and trials of life 
— never absent at any time, but often peculiarly besetting its momen- 
tous unsteady commencement. Need it be said then that the efforts 
should be proportioned to the difficulties? and with the determined 
and rational exertion of human means, conjoined with humble and faith- 
ful dependence on more than human guidance and strength, such efforts 
will never prove unsuccessful in the end. 

669. But it is more pertinent to our particular object to indicate the 
modes by which the mind and body reciprocally promote each other's 
health; and much in regard to this may be summed up in the Platonic 
axiom that these should be well balanced in their exercise and activity. 
The undue, or too prolonged, occupation of the mind with deep study 
or concentrated thought abstracts some of the supply of blood and of 
vital energies from the bodily functions; these consequently suffer and 
fall into weakness and disorder, whilst the nervous system, the ma- 
terial organ of the mind, becomes ultimately exhausted by the con- 
tinued excitement, and refuses to perform some of its manifold func- 
tions; hence stupor, paralysis, or organic weakness of some kind may 
ensue; or there may be morbid erethism or irritation in the midst of 
general weakness; and delirium, spectral illusions, sleeplessness, tre- 
mors, and spasmodic or painful affections, may be the consequence. 
Mental idleness, on the other hand, not only weakens the intellect 
through disuse, but, by inducing habits of indolence and self-indulgence, 
pampers the body and perverts its proper functions, degrading them 
to an approximation to brutal or even vegetable life. Moderate and 
well-timed exercise refreshes the mental powers, and enabling them to 
apply with renewed vigour, increases their power and sphere of action. 
So likewise, pleasing mental impressions, such as are afforded by beau- 
tiful scenery, congenial associations, and interesting pursuits, heighten 
the benefits of bodily exercise, and give to all the faculties that re-nas- 



NATURE OF SLEEP — YAWNING. 



477 



cent energy which is well expressed by the terra recreation. A simi- 
lar advantage accrues from varying the kind of mental occupation ; 
thus music, drawing, amusing games, and light reading, are to many, 
more effectual than absolute rest, in refreshing the mind after severe 
study or close application. In like manner, intellectual tasks of dif- 
ferent kinds may be profitably alternated with each other, just as the 
several muscles of the body may be beneficially exercised in succession 
(§ 664.) Analogous rules too apply to the moral emotions, in so far 
as they can be placed under the direction of the individual; there is 
in most energetic minds a natural or habitual succession of high and 
low spirits, of lights and shadows in the mental hemisphere, which, how- 
ever trying and hazardous when in excess, if occurring in moderation, 
gives to thought a renewed vigour which is wanting in minds of more 
perfect placidity. 

SLEEP. 

670. It would be altogether a work of superfluity to expatiate on 
the health-giving influence of a due amount of tranquil sleep. It is 
obviously the chief means which nature employs for recruiting the ex- 
hausted energies of the animal functions; and some of the causes and 
consequences of its failure have been already noticed as constituent ele- 
ments of disease (§ 23, 56, 64, 154.) Sleep appears to consist in a 
more or less complete suspension of the cerebral or sensorial functions, 
accompanied by an increase of the spinal and organic nervous influ- 
ence ; and we have suggested, that a modification in the distribution 
of the blood through the nervous centres may be instrumental in thus 
periodically reducing the activity of parts which are not essentially 
concerned in the maintenance of life (§ 153.) The sensorial functions 
are, however, only impaired : they are not completely suspended, for 
a proof of their partial continuance during sleep is afforded not only 
in dreaming, but also in the voluntary movements, which are often 
performed to remove uncomfortable sensations, and even in the act of 
awaking when such sensations attain a certain degree of intensity. 

The approach of sleep is announced by a sense of drowsiness, which 
consists of a dulness of sensation, perception, and thought, and of an 
indisposition to exertion. Gaping and yawning, although viewed as 
symptoms of sleepiness, really result from efforts to resist it: they 
seem to be movements designed to throw certain muscles, especially 
in the throat and neck, into a state of tension, during which the sen- 
sation of drowsiness is for the moment increased to a degree which is 
rather agreeable than otherwise, but which is speedily followed by its 
diminution. It is very probable that these movements tend to re-ex- 
cite the slackening cerebral circulation, by momentarily impeding it, 
and then allowing it to flow again with augmented force ; thus in a degree 
analogous to the hydraulic process of flushing. Sleep closes the re- 
lations of the senses to all moderate impressions from the external 
world, and suspends almost all voluntary movements, among which are 
to be reckoned those that are supplementary to the process of respira- 
tion (§ 628.) The respiration is therefore rendered less frequent and 
more prolonged than when awake, and the pulse is also lowered. The 
circulation and changes of the blood being thus reduced during sleep, 



478 



HYGIENICS — SLEEP. 



there is also less power of maintaining animal heat; hence the chilli- 
ness commonly experienced, and the increased susceptibility to cold, 
unless the body is better protected than usual by clothing. Hence, 
too, the relaxation of the skin after slight febrile excitement, inducing 
perspiration, which commonly occurs first during sleep. 

671. The circumstances which promote sleep are chiefly influences 
which impair the activity of the animal functions, and which withdraw 
all causes of excitement both from mind and body. A moderate de- 
gree of corporeal and mental fatigue; the absence of all uneasy sen- 
sations ; a comfortable posture, affording the most complete rest to the 
limbs and voluntary muscles; freedom from the feeling of either hun- 
ger, thirst, or repletion, cold or heat; the recurrence of the usual hour 
for repose, and of the stillness and darkness of night, — are favourable 
to the induction of sleep. In addition to these agencies, which act 
negatively by excluding excitement, there are also others which often 
promote sleep, by causing gentle and monotonous sensations or ideas 
that have the effect of lulling into somnolence: such, for example, as 
the various expedients for hushing infants to rest, by rocking, patting 
the back, and singing, and with adults, gentle friction, reading, prosy 
talking, and other sensorial impressions, which slightly tire without ex- 
citing. These probably operate by diverting the attention from other 
occasional feelings or noises, which tend to disturb. The passes of 
mesmerism no doubt act upon this principle. The common plan of 
counting or reciting oneself to sleep, owes what little efficacy it pos- 
sesses, to its abstracting the entire attention to an uninteresting object. 

672. The influences which prevent or disturb sleep are for the most 
part the reverse of those above described. Any undue excitement or 
sensation of body or mind, whether of a painful or a pleasurable na- 
ture ; strong, sudden, or startling impressions on the senses ; uneasy pos- 
tures ; extreme fatigue or exhaustion ; oppressed or imperfect breathing ; 
palpitation of the heart; hunger, thirst, nausea, flatulence, and various 
other (often undefinable) sensations in the viscera; extremes of tem- 
perature ; coldness of the extremities ; irregularity in the habits of seek- 
ing repose; — these are the ordinary causes of sleeplessness. They ope- 
rate either by directly exciting the sensorium to a degree inconsistent 
w T ith the suspension of its functions; or by so much reducing or dis- 
ordering the power of the spinal medulla, that it is incapable of sus- 
taining the respiratory movements without the aid of voluntary effort. 
In the former case, positive pain, uneasy sensations, or exciting trains 
of thought, are present. In the latter there may be the desire to 
sleep, but no sooner does its commencement suspend the voluntary 
efforts by which the breathing is aided than this process becomes im- 
perfect, and the person starts with a feeling of oppression or impend- 
ing suffocation, which is often embodied by an incipient dream into 
nightmare, or into the notion that he is being pursued by demons, or 
falling down a precipice, or undergoing some other horrible catastro- 
phe. The sleepless hallucinations of delirium tremens, and similar 
disorders, in which continued excitement of the nervous system has 
exhausted the energy that is required in the medulla for the mainte- 
nance of respiration and muscular tone during sleep, are of this nature. 



MEANS OF PROMOTING! SLEEr. 



479 



673. The loss of rest is so seriously detrimental to health, that it is 
of the utmost importance in a hygienic point of view that this result 
should be obviated; and besides avoiding, so far as may be possible, the 
several causes of wakefulness just specified, bad sleepers should strictly 
attend to the following directions for their regimen, rather than resort 
too hastily to hypnotic drugs, which, although sometimes useful and 
necessary as temporary expedients, lose their power by habitual use, 
and produce other evil consequences which render their long continu- 
ance improper. 

Bad sleepers should make a regular practice of early rising: it may 
cost them some effort at first ; but if they desire to have sound rest, 
they should seek it at the natural time, and not late in the morning 
when the excitements of the day begin. Their hours for meals and 
exercise should also be early and very regular (§ 644, 662 ;) both in 
order to promote that state of health most conducive to ease and free- 
dom from suffering, and also to secure the accomplishment of the pro- 
cesses of digestion, and consequent excretion or eructation before night, 
which is the proper period for repose (§ 643, 4.) Exercise should be 
taken as freely in the open air as the strength will permit without 
causing lasting fatigue; and if walking or riding cannot be borne 
without such result, driving or sitting out in the open air several hours 
in the day may often be resorted to as an efficient substitute ; this acts 
by gradually and gently fatiguing the senses through the operation of 
light, air, and sound, whilst the organic energies are refreshed and in- 
vigorated by their salutary influence (§ 652.) As the hour of retire- 
ment for rest approaches, every description of exciting agency should 
be avoided. The latest meal should be taken at least an hour before 
bedtime, and tea, coffee, and all vegetable matters apt to decompose 
in the stomach and generate gas should be excluded from it. Weak 
persons and others who are under the influence of fatigue, may often 
advantageously take a little wine or alcoholic mixture at this meal ; its 
operation is to counteract the nervous excitement induced by exhaustion 
and weakness, and so it becomes composing and hypnotic (§ 64, 155.) 
All active exertion, whether of body or mind, should be carefully 
shunned at this time. Conversation or reading should relate to common- 
place or tranquillizing subjects, which neither require much attention 
nor excite the feelings or imagination. The very preparation of un- 
dressing should be simplified as much as possible, and all superfluous 
proceedings, general washing, &c, should be postponed until the fol- 
lowing morning. Much might be said about the arrangement of the 
bed and its appendages, and the posture best suited for tranquil repose ; 
but it will be sufficient here to suggest that everything should be made 
as comfortable as possible, short of the risk of causing relaxation by 
excessive softness or abundance of covering. A soft upper mattress of 
hair, or of wool and hair, is always preferable to a feather-bed, not 
only because it is less relaxing, but also because it gives a more elastic 
and even support to the body and limbs, and prevents that sinking in 
of the body which fatigues a weak back by bending it. The posture 
that is generally most easy is lying on the right side, for this affords 
such support to the two weighty organs, the liver and heart, as ob- 



480 



HYGIENICS — SLEEP. 



viates their pressing on the hollower viscera. The various expedients 
for inducing sleep, like repeating lines of poetry, and counting num- 
bers, and other artifices, which act by diverting attention from exciting 
trains of thought, seldom succeed with the really wakeful. The plan 
devised by the late Mr. Gardner, and mentioned by Dr. Binns in his 
"Anatomy of Sleep," (p. 391,) has not proved more successful in my 
experience. It is founded on the same principle of abstracting the 
attention, by directing the mind to the imagined vision of the breath 
issuing from the mouth during expiration. A proceeding, which I 
have found to answer better, consists in attempting to imitate the way 
in which a person breathes during sleep, by making the respirations, 
particularly the expirations, deeper and more prolonged than usual, 
and by giving to them somewhat of a sonorous character from the re- 
laxed and imperfectly open state of the glottis. This often excites 
drowsiness, probably by gently retarding the return of blood from the 
brain; and this drowsiness may lead to sleep ; but it frequently hap- 
pens with this, as with all other voluntary attempts to procure sleep, 
that the continuance of the effort breaks the spell through the awaken- 
ing influence of sustained attention; this objection especially applies to 
first attempts at practising such invocations of Morpheus. The expe- 
dient recommended by Dr. Franklin, for the restoration of sleep that 
has been broken, namely rising and shaking the bed, with the view to 
change the air enveloped in its coverings, is sometimes successful, par- 
ticularly in hot weather. 

674. The amount of sleep that is most conducive to health varies 
considerably with age, sex, employment, and constitutional and ha- 
bitual peculiarities. Infants pass the greater part of the day as well 
as the night in sleep; and children, up to the age of six years, gene- 
rally require at least twelve hours of repose, besides an hour or more 
in the middle of the day. At about this age, the sleep at noon may 
be discontinued, but the night sleep can hardly be abridged with ad- 
vantage, until about the tenth year, and then only to a moderate ex- 
tent, up to the period of puberty, after which it is for the most part 
proper gradually to reduce the period of rest to nine or ten hours ; no 
farther diminution beyond this is expedient until the cessation of 
growth, after which another hour or two may be taken away. The 
average amount of daily sleep that is beneficial in adult and middle 
ages may be stated at eight hours. In more advanced life the same 
extent of sleep is not less serviceable where it can be procured; but the 
capacity for sleep usually diminishes at this period, and wakefulness 
or disturbed rest becomes a common complaint of old age. Attention 
to the precautions recommended above (§ 678) will however often re- 
store the capability ; and, even if they do not sleep, aged persons should 
remain an increased length of time in bed, for the sake of warmth and 
rest, which their reduced calorific and muscular powers render more 
necessary than they once were. 

Females commonly stand in need of more sleep than males; and 
during pregnancy and lactation additional rest are especially demanded, 
to assist the supplementary nutritive processes brought into operation 
in these conditions. In such cases, too, the loss of sleep is attended 



AMOUNT OF SLEEP REQUIRED. 



481 



and followed by peculiarly injurious results to the nervous system and 
to the general nutrition, manifested in the form of mental derange- 
ment, impaired vision, deafness, paralysis, palpitation, convulsions, 
tremors, anorexia, wasting, diarrhoea, &c. Under these circumstances, 
it is a main object of treatment to procure sleep, and in addition to 
regiminal measures already suggested, nervous sedatives or hypnotics 
of the least depressing kind may be administered. Persons who are 
just convalescent from acute diseases, or who are otherwise weakened 
and reduced, require and generally obtain more sleep than in ordinary 
health, and it is so efficient an influence in the promotion of recovery, 
that artificial means are sometimes wisely adopted to ensure it. So, 
likewise, those who use much active exertion need a longer period of 
repose than those who are of sedentary habits; and the same may be 
said of persons who exercise their minds greatly; but as mental excite- 
ment does not dispose to sleep in the same degree as bodily fatigue, it 
is the more important that all persons whose intellectual powers are 
much strained, should also take such bodily exercise as may serve to 
maintain the balance, and secure the due return of rest. 

675. Salutary as the operation of sleep is at its proper time and in 
its due degree, it may prove -injurious if indulged in to excess and at 
improper seasons. Too much sleep slackens the circulation, diminishes 
excretion and muscular nutrition, and causes general plethora or par- 
tial congestions, and in persons disposed to such a result, promotes the 
accumulation of fat. It also weakens the muscular and sensorial 
powers through the inactivity of their organs, and gives undue as- 
cendency to the spinal function: hence it often leads to a tendency to 
spasmodic and other nervous disorders of the system, which may run 
on into fits of hysteria or even epilepsy. In persons liable to this 
class of disorders, an abridgement of the hours of sleep is often very 
beneficial; and this is best effected by gradually establishing the habit 
of early rising. Undoubtedly the most fitting time for sleep is the 
night, and although in temperate latitudes the nights are in summer 
too short, and in w T inter too long for the amount of needful repose, yet 
the more nearly this is continued to the period when darkness and 
silence warn to rest, the better for the permanent comfort and well- 
being of the body. On the score of health, then, it is advisable that 
even adults should retire to rest, in summer especially, as many hours 
before midnight as can be spared after night closes; in order that they 
may be enabled to rise at or as soon after sunrise as the proper com- 
plement of sleep has been enjoyed. But, inasmuch as the usages of 
society and the business of life often establish unavoidable demands on 
the night hours of many persons, the compromise of retiring one hour 
before midnight should be enjoined for the sake of health, and accom- 
panied with an exhortation to early rising, enforced by a description 
of the refreshing and invigorating influences of the morning air, with 
all its exhilarating concomitants of light and sounds. 

EXCRETION. 

676. The absolute necessity of efficiency in the processes of excre- 
tion for the maintenance of health has been incidentaliv illustrated by 

31 



482 



HYGIENICS — EXCRETION. 



the numerous instances that have been cited in the preceding pages, 
in which their failure has led to the production of disease (§ 68, 248 
— 254, 385, &c. ;) and although such instances have commonly been 
cases of disorder that have required the employment of medicinal mea- 
sures,, yet it must be borne in mind that the regularity and completion 
of the processes of elimination may be generally so far promoted by 
regiminal influences, that these deserve a place among hygienic agents. 
Depending, as excretion does, on the activity of the processes — of cir- 
culation, which furnishes the supply of blood to the secreting organs; 
of respiration, which maintains the essential properties of that blood 
by renewing its chief chemical agent; of assimilation, which adds to 
its materials ; of muscular contraction, which effects the expulsion of 
the excrcmentitious matter; and of sensation, which takes cognizance 
of the need of its evacuation ; — it might be anticipated that the proper 
performance of thii office (excretion) will much depend on the vigorous 
condition of these several processes, which with it compose the sum 
of the general health. Hence many of the hygienic measures already 
recommended as contributing to sustain those several processes, are 
likewise efficacious in maintaining due excretory power. Thus a pro- 
per regulation of food, solid and liquid (§ 642 — 644,) and of exercise 
(§ 660 — 662,) is one very important step towards favouring the ex- 
cretions; and the functions of the skin and kidneys, and, in a less de- 
gree, those of the liver and intestines, are influenced by clothing, tem- 
perature, air and sleep (§ 646—649, 652 — 655.) 

It will be sufficient here to enumerate a few of the most available 
measures that may be employed for regulating the action of the bowels, 
the kidneys and the skin, during ordinary health. 

677. No circumstance tends more to promote the proper action of 
the intestines, than the punctual habit of daily devoting a fixed and 
sufficient time to their evacuation. Medical writers have long insisted 
on* the importance of punctuality in this: but they have not generally 
recognised the necessity of allowing a sufficient time for the proper 
completion of the act ; yet with persons of costive habit this is far from 
being a secondary consideration. With individuals whose bowels act 
readily, an efficient peristaltic action forwards at the accustomed time 
the feculent matter, in such consistence and quantity as is fitted for 
prompt and easy expulsion ; but with those who have torpid bowels 
(and they constitute a very numerous class, even among healthy per- 
sons,) the excrement is harder and the intestinal movement more slow, 
and instead of being all in the rectum ready for expulsion at the ap- 
pointed hour, more or less of it is still commonly lagging behind in 
the sigmoid flexure, or even above it, and cannot be discharged by a 
momentary effort. Nor will violent straining (which is moreover in- 
jurious in other respects (§ 64, 289,) properly aid in the process. Re- 
peated gentle and sustained abdominal contractions, assisted, if neces- 
sary, by kneading pressure or friction downwards in the left iliac re- 
gion, in the direction of the sigmoid flexure, with occasional variation 
in the position of the body, are the safest and most efficient means for 
accomplishing the object, but they require the sacrifice, of a few mi- 
nutes of time, and if the end were not worth the sacrifice I would not 



INTESTINAL — HABITUAL APERIENTS. 



483 



trespass upon the delicacy of my readers by this allusion to $o disgust- 
ing a subject. These expedients are more easy and natural, and less 
injurious than the employment of enemata; of which, even the simplest 
kinds, if habitually used, tend to injure the tone of the bowel, and to 
impair its natural action. 

678. Other means may be mentioned as serviceable under ordinary 
circumstances, in keeping up a regular and sufficient action of the 
bowels; such are the use of brown or rye bread instead of white; oat- 
meal porridge taken at night; revalenta or lentils ; white mustard seed; 
stewed prunes; tamarinds: and baked apples; all of these operate by 
adding either a mechanical or a chemical irritant to the feculent mass, 
and, therefore, may prove objectionable in consequence of irritating 
too violently or otherwise disordering the alimentary canal. The same 
may be said of the addition of toasted bacon to the breakfast, and of 
a quantity of fruit to the dinner. A more harmless, and occasionally 
more efficacious expedient, is found in drinking a large draught of cold 
spring water at first rising, and this is useful for other purposes like- 
wise. With some persons malt liquors promote the action of the 
bowels. A walk before breakfast for the more robust, or a walk or 
ride immediately after that meal for others, often contributes to the 
same end ; and in some instances such exertions as particularly bring 
into action the abdominal and other muscles of the trunk, as for in- 
stance, digging, and similar gardening occupations prove more effec- 
tual. 

679. Lastly, we must not omit mention of the habitual use of gentle 
aperient medicines, as the safest and most efficacious means for se- 
curing an adequate intestinal action in persons with whom sedentary 
occupations or other circumstances absolutely prevent the adoption of 
more simple hygienic measures for the accomplishment of the same pur- 
pose. Undoubtedly, it is preferable to avoid the constant use of me- 
dicine, if dietetic or regiminal management can be so conducted as to 
supersede the necessity for it ; but long observation has convinced me 
that this cannot always be effected, and that then, as a prophylactic 
resource, a little daily pill is preferable to the practice of loading the 
stomach with fruit or other indigestible matter, with the object of sti- 
mulating the lower bowel. The drugs which commonly answer best 
as habitual laxatives, are rhubarb and aloes, both of which, on account 
of their bitter properties, combine somewhat of a tonic with their ape- 
rient influence. Aloes is the most efficacious, and if properly managed, 
does not lose its aperient power, even after many years of daily use. 
I know of one instance in which it was constantly employed for fifty- 
seven years, with unquestionably beneficial results, and the individual 
who took it, in spite of very sedentary habits, retained uncommon vi- 
gour both of body and mind until within a year of his death, which 
occurred at the age of eighty-seven. By far the best mode of admi- 
nistering aloes as an habitual aperient, is in combination with a little 
mastich, and made into a mass with alcohol, which renders the pill less 
soluble in the stomach, and therefore more capable of acting on the 
lower part of the canal. The proportion which I commonly use, con- 
sists of three parts of watery extract of Barbadoes or socotrine aloes 7 



434 



HYGIENICS — EXCRETION. 



with one* of mastich powder, two or three grains of this is to be taken 
in the form of a pill at dinner or at bed time daily. This has no ten- 
dency to excite hemorrhoids, provided an occasional dose of blue pill 
be administered to keep up a sufficient action of the liver. In several 
instances I have found it to operate more satisfactorily on joining to 
it a few grains of inspissated ox-gall. For weakly persons a grain of 
sulphate of iron or quinine may also be added with advantage. 

680. The excretion of urine is less generally an object of solicitude 
than is that of the bowel, yet it is remarkable how commonly persons 
have their attention drawn to it, as they advance in years, often from 
experiencing discomfort in consequence of its irregularity or deficiency: 
such irregularities are undoubtedly an important element in a vast 
number of diseases, whether serious or trivial. It would occupy too 
much space to advert fully here to disordered excretion of urine; in- 
deed the subject has been touched on iu almost every part of the pre- 
sent work ; it is only necessary, therefore, farther to mention a few 
common hygienic influences by which the urinary excretion may be 
promoted or rendered free. 

The quantity of urine, and consequently in a general way, its clear- 
ness and the lowness of its specific gravity, will be proportioned to the 
amount of fluid ingesta; but its increased flow is more certain to fol- 
low when fluid, especially if this be water, pure, or with a very slight 
addition of vegetable or animal nutriment, is taken on an empty sto- 
mach. Thus a large draught of spring water drunk at first waking in 
the morning, or an hour before dinner, is almost surely followed by a 
free flow of clear urine. The result, however, is promoted by such 
moderate exercise as excites the heart's action without causing perspi- 
ration. Some kinds of exercise peculiarly augment the secretion of 
the kidneys; especially such as bring the muscles of the loins into ex- 
ercise, for instance, gardening, and trotting on horseback ; these there- 
fore should be recommended to persons whose renal functions are de- 
fective, especially if they be liable to lithuria ; for when the watery con- 
stituent of the urine is increased, the risk of any deposit taking place 
in the urinary apparatus is diminished. Similar means, if regularly 
employed, are useful also in gouty and rheumatic habits; and appear 
really to establish an increased elimination of solid matter, as well as 
of water, by the kidneys (§ 231, 257 ;) in this respect their operation 
differs from that of medicinal diuretics, which unless very judiciously 
administered, excite for the time, and leave the secreting power ex- 
hausted afterwards. This is the chief objection also to certain diuretic 
beverages in common use, but as temporary expedients ; such for in- 
stance as gin, Hollands, or whisky, diluted with water; spruce beer; 
imperial drink (water saturated with bitartrate of potass, sweetened 
and flavoured,) leek or onion broth, barley-water, linseed and tamarind 
tea, and Seltzer water. Grapes, currants, and other ripe sub-acid 
fruits, are also occasionally serviceable in the same way. 

681. The regular evacuation of the bladder, when it is distended to 
a certain degree, is prompted by the sensation which its fulness ex- 
cites, but this happens variously in different individuals; some, either 



U E I N E — PERSPI R A % 1 0 N . 



4 85 



not feeling or easily resisting the inclination, and others yielding too 
frequently to the impulse. The latter habit is extremely inconvenient, 
especially on account of its disturbing the sleep at night;. but the op- 
posite custom of too long retaining the urine may also prove pernicious 
in various ways already hinted at (§ 68,) and it should therefore be 
carefully avoided. In circumstances interfering with a proper observance 
of this caution, the urgency of the inclination may be diminished by 
limiting the amount of liquids swallowed, and by promoting the acti- 
vity of the cutaneous excretion by means of warm clothing and ex- 
ternal heat. 

()82. ■ The objects of the perspiratory secretion are not entirely known ; 
but its uses are recognised, — in evacuating from the superficial vessels 
superfluous water, acid, and oily matter, when they are distended or 
excited by the influence of prolonged heat or exertion; in tending to 
cool the surface thus heated by evaporation, and to remove the irrita- 
tion of distention or obstruction ; by relaxing the tissues ; and through 
the same softening operation, in rendering the skin more pervious to 
the chemical action of the air on the blood, and to the vital influences 
reciprocated between the blood and the tissues. 

The excretion of the skin is, as has been mentioned, materially af- 
fected by clothing, exercise, temperature, and air; these agencies in- 
deed are the chief means by which it is modified during health. 

Other hygienic measures whereby the action of the skin may be pro- 
moted are bathing, washing, and friction. The chief operation of all 
these upon the skin is through its functions of circulation and secre- 
tion; and in proportion as they are freely used, they may extend their 
influences to the whole system. Thus warm bathing of the entire body, 
as it increases the amount and motion of the blood in the cutaneous 
vessels, and the perspiration from them, necessarity diminishes the sup- 
ply to internal organs, and consequently the activity of their secretions. 
If continued long, or repeated frequently, general weakness is very 
apt to be induced, the surface remaining in a relaxed state. But the 
same objection does not apply to the occasional use of the warm bath, 
or the practice of daily washing the whole surface with tepid sponging 
or the shower-bath, followed by friction ; these are highly salutary 
means tending as they do to keep the skin in a free and active condi- 
tion, and are well suited to persons of languid circulation. In the ma- 
jority of healthy subjects, however, this object is better obtained by 
washing with cold water, and in the robust, even by the cold shower 
or plunge bath, which indirectly excites the functions of the skin by 
first constricting its vessels, and throwing the blood on internal organs, 
and then, through its impression on the incident nerves, by causing 
the excitement of reaction, which soon restores the superficial circula- 
tion in redoubled force as indicated by the concomitant redness and 
glow (§ 80.) This reaction is farther promoted by vigorous friction of 
the whole surface with coarse towels or horse-hair gloves, which operates 
not only by stimulating the cutaneous vessels and glands, but also by 
the muscular exertion exciting the heart to stronger and more frequent 
contractions; for the same reason a brisk walk after bathing is often 



486 



HYGIENICS — EXCRETION. 



useful. If after cold bathing the reaction is incomplete, and the skin 
remains pallid, chilly, and contracted, it may be inferred that the 
cold has been too long applied, that the cutaneous functions remain 
impaired, and that internal organs continue to be more or less con- 
gested. Or, if, after complete reaction, unpleasant sensations of fa- 
tigue, languor, chilliness, or headache, are experienced, this indicates 
that the cold has been too depressing or exhausting ; in either of these 
cases tepid bathing or washing should be substituted. The vapour- 
bath, with its frequent accompaniments of shampooing and various 
aromatic and stimulant applications, although powerful remedial agents 
in disease (especially in cases of chronic rheumatism and its conse- 
quences,) are too exciting and exhausting to be recommended as ordi- 
nary means to be adopted for the preservation of the health. 



THE END. 



